Chung and colleagues1 report an outstanding study that is long overdue. These authors are recognized by the international hand surgery community as leaders in clinical epidemiology of upper extremity conditions. This study, funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Institutes of Health answers a fundamental question related to fractures of the wrist in elderly individuals that has been asked many times and has never been answered. The mere fact that enough patients were recruited to allow randomization from 24 health systems that included centers here and abroad in and of itself was an accomplishment and provides significant strength to the conclusions. As a practicing hand surgeon, not only have I used all of these techniques but I have found each approach for treatment of the distal radius in patients aged 60 years or older effective.
The authors measured function and radiological alignment at 1 year. Given that the plate fixation demonstrated significantly better radiological alignment through the follow-up period, the hope is that this cohort will have less incidence of degenerative arthritis and carpal instability compared with patients who were treated with casting and subsequent settling in malunion. Will the patients with residual deformity in terms of radial inclination or dorsal tilt be more likely to develop carpal instability? Prospectively following this study group will be worthwhile and provide more answers over a longer time frame.
The authors state that casting generally needs fewer follow-up visits. I respectfully disagree with this. The patient who receives closed reduction and application of a cast (either short arm, long arm, or sugar-tong) in the emergency department must be followed up closely to make sure that the fracture does not displace. As the initial edema resolves, the fracture can be prone to displacement; if left in a malreduced position, the outcome can be adversely affected.
Randomized participants received surgery mean of 8.6 days after fracture. While this time frame is certainly acceptable, it should be emphasized that surgical intervention should take place as soon as possible to minimize time off work and minimize the liability of joint immobilization that contributes to fracture disease (defined as arthrofibrosis and dystrophy).
Although the cost of plating is higher, the authors noted locking plate participants had significantly greater return of hand grip and pinch at 6 weeks after surgery compared with the other arms. The financial value of this should be estimated, allowing the elderly patient earlier independent function that may preclude the cost of an aide or health care professional who helps with bathing, dressing, and other activities of daily living. While this was not formally measured in the study, a follow-up study would clarify this.
The authors imply that positive ulnar variance is inconsequential in treatment of the distal radius fracture. Positive variance can be associated with ulnar impaction and distal radioulnar joint dysfunction and may require treatment such as an ulnar shortening or a Darrach procedure.
In hand surgery, randomized clinical trials are very difficult to perform and the hand literature is sparse with such studies. This study may guide treatment, decrease litigation, contribute to guidelines for cost-effective care, and resolve the dilemma for many hand surgeons on how to treat distal radius fractures in patients aged 60 years or older.
Published: January 18, 2019. doi:10.1001/jamanetworkopen.2018.7078
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Levin LS. JAMA Network Open.
Corresponding Author: L. Scott Levin, MD, Perelman School of Medicine, Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market St, Sixth Floor, Philadelphia, PA 19104 (email@example.com).
Conflict of Interest Disclosures: None reported.
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Levin LS. Wrist Fractures in Patients 60 Years or Older—To Plate or Cast? JAMA Netw Open. 2019;2(1):e187078. doi:10.1001/jamanetworkopen.2018.7078
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