Description: OTA 2002 - Session 10 Session X - Upper Extremity Sun., 10/13/02 Upper Extremity, Paper #67, 10:41 AM A Randomized Controlled Trial of Indirect Reduction and Percutaneous
Fixation versus Open Reduction and Internal Fixation for Displaced Intraarticular
Distal Radius Fractures 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 indirect reduction and percutaneous fixation
with open reduction and internal fixation for repair of displaced intraarticular
distal radius fractures in a multicenter randomized clinical trial. Methods: A total of 179 skeletally mature patients 16 to 75 years
of age who had displaced intraarticular distal radius fractures received
either indirect percutaneous reduction and external fixation ( N =
88) or open reduction internal fixation (ORIF) ( N = 91). Each fracture
was reduced to a standard of acceptable radiographic parameters. Patients
were evaluated at 6 weeks, 6 months, and 1 and 2 years. Function was measured
by using the upper extremity module of the Musculoskeletal Function Assessment
to represent the primary endpoint. Pain, the Jebsen-Taylor functional test
score, range of motion, and grip and pinch strength were secondary outcomes.
Repeated measures analysis of variance was used to compare outcomes between
the two study groups over time. Results: Primary and secondary outcome measures improved significantly
the 1st year. By 2 years, the mean Jebsen Taylor and pain scores were within
half a standard deviation of the control population scores for both study
groups. Upper extremity function improved more rapidly after indirect reduction
as compared with ORIF; a 13-point score difference was noted in favor of
indirect reduction at the 6-month evaluation ( P = 0.037). After adjusting
for repeated measures over the 2-year study period, indirect reduction resulted
in significantly better upper extremity function compared with ORIF ( P = 0.014). Pinch strength was also significantly better after indirect reduction
( P = 0.020), with similar trends for grip strength ( P = 0.448)
and Jebsen Taylor scores ( P = 0.059). There was no statistically
significant difference in the radiographic restoration of anatomic parameters
( P >0.05). Twelve patients (14%) healed with residual intraarticular
step deformity in the indirect reduction group compared with 13 patients
(14%) in the open reduction group ( P = 1.0). Only three patients
(3%) in the indirect group and two patients (2%) in the ORIF group had step
deformity of more than 2 mm at union ( P = 0.679). Residual step and
gap deformity were associated with development of radiographic osteoarthritis
and also with poor function scores ( P <0.05). Discussion: Indirect reduction and percutaneous fixation results
in more rapid return to function and superior functional outcome within
2 years from injury as compared with ORIF for repair of displaced intraarticular
distal radius fractures, provided that intraarticular step and gap deformity
is minimized. Conclusion: This is the first study with results showing that ORIF of intraarticular distal radius fractures should be preceded by
attempts at closed reduction, percutaneous stabilization, and external fixation.
Only if the reduction cannot be obtained with closed percutaneous methods
should the fracture be opened and internally secured.
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