Description: OTA 2002 - Session 10 Session X - Upper Extremity Sun., 10/13/02 Upper Extremity, Paper #65, 10:29 AM A Randomized Controlled Trial of Closed Reduction and Casting versus
Closed Reduction and External Fixation for Distal Radius Fractures with
Metaphyseal Displacement but Without Joint Incongruity Hans J. Kreder, MD, FRCS(C) ; Douglas P. Hanel, MD; Julie
Agel, MA, ATC; Michael D. McKee, MD, FRCS(C); Thomas E. Trumble, MD; University
of Toronto, Toronto, Ontario, Canada; Harborview Medical Center, Seattle,
Washington, USA; University of Minnesota, Minneapolis, Minnesota, USA (-OREF
Grant) Purpose: We compared closed reduction and casting with closed
reduction and external fixation for repair of distal radius fractures with
metaphyseal displacement but without joint incongruity in a multicenter
randomized clinical trial. Methods: We randomized 113 eligible patients with distal radius
fractures with metaphyseal displacement but without joint incongruity to
repair with either closed reduction and casting ( N = 59) or closed
reduction and external fixation ( N = 54). For five patients randomized
to cast treatment, an open procedure was required within the first 3 weeks
because of significant loss of correction. One patient randomized to external
fixation underwent open reduction and internal fixation because of displacement
of a previously undisplaced partial articular fracture. The patients were
evaluated at 6 weeks, 6 months, and 1 and 2 years. Upper extremity function,
as measured by using the upper extremity module of the Musculoskeletal Function
Assessment, represented the primary endpoint. Pain, Jebsen Taylor functional
test score, range of motion, and grip and pinch strength were evaluated
as secondary outcomes. Repeated measures analysis of variance was used to
compare outcome between the two study groups. We compared the results at
each time interval by using the Student's t -test or chi square test
to evaluate the outcome data. Results: By 2 years, Jebsen Taylor scores and pain scores were
similar to population age- and sex-matched control scores in both study
groups. At all evaluation time points, there was a trend toward better function
in the external fixation group; however, this did not reach statistical
significance ( P <0.05). The mean difference in upper extremity
function scores at 2 years (the primary endpoint) was 5.5 in favor of external
fixation (power = 0.161). Results of approximately 896 patients would have
been required to obtain 80% statistical power. There were six pin site infections in the external fixation group (14%),
with one deep infection requiring curettage (2%). One patient in the external
fixation group (2%) and two in the cast group (6%) developed a reflex sympathetic
dystrophy ( P = 0.585). There was no statistically significant difference
in the radiographic restoration of anatomic parameters, although there was
a trend toward better length and palmar tilt restoration with use of external
fixation ( P >0.05). Discussion and Conclusions: Upper extremity function, Jebsen Taylor,
and pain scores, and grip strength improved significantly the 1st year of
the study for all patients. There was a trend toward better functional,
clinical, and radiographic outcomes with use of immediate external fixation
for distal radius fractures with metaphyseal displacement and a congruous
joint.
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