Assessment of Anatomic Restoration of Distal Radius Fractures Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial

Abstract

Importance: The value of precise anatomic restoration for distal radius fractures (DRFs) in older adults has been debated for many decades, with conflicting results in the literature. In light of the growing population of adults aged 60 years and older, both fracture incidence and associated treatment costs are expected to increase.

Objective: To determine the association between radiographic measures of reduction and patient outcomes after DRF in older patients.

Design, setting, and participants: Data were collected from the Wrist and Radius Injury Surgical Trial (WRIST), a multicenter randomized clinical trial of DRF treatments for adults aged 60 years and older (enrollment from April 10, 2012, to December 31, 2016, with a 2-year follow-up). Data analysis was performed from January 3, 2019, to August 19, 2019. WRIST participants who completed 12-month assessments were included in the study. According to the biomechanical principle of alignment, 2-phase multivariable regression models were adopted to assess the association between radiographic measures of reduction and functional and patient-reported outcomes 12 months following treatment.

Interventions: Participants were randomized to receive volar locking plate, percutaneous pinning, or external fixation. Those who opted for nonoperative treatment received casts.

Main outcomes and measures: Hand grip strength, wrist arc of motion, radial deviation, ulnar deviation, the Michigan Hand Outcomes Questionnaire (MHQ) total score, MHQ function score, and MHQ activities of daily living score were measured at 12 months following treatment.

Results: Data from 166 WRIST participants (144 [86.7%] women; mean [SD] age, 70.9 [8.9] years) found that only 2 of the 84 correlation coefficients calculated were statistically significant. For patients aged 70 years or older, every degree increase in radial inclination away from normal (22°) grip strength in the injured hand was 1.1 kg weaker than the uninjured hand (95% CI, 0.38-1.76; P = .004) and each millimeter increase toward normal (0 mm) in ulnar variance was associated with a 10.4-point improvement in MHQ ADL score (95% CI, -16.84 to -3.86; P = .003). However, neither of these radiographic parameters appeared to be associated with MHQ total or function scores.

Conclusions and relevance: The study results suggest that precise restoration of wrist anatomy is not associated with better patient outcomes for older adults with DRF 12 months following treatment. Surgeons can consider this evidence to improve quality of care by prioritizing patient preferences and efficient use of resources over achieving exact realignment.

Trial registration: ClinicalTrials.gov identifier: NCT01589692.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Chung reported receiving funding from the National Institutes of Health and book royalties from Wolters Kluwer and Elsevier outside the submitted work. Ms Shauver reported receiving grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.

Figures

Figure.. Multivariable 2-Phase Regression Plots

The shaded area indicates the 95% CI. Vertical line indicates the normal value for each independent variable (eg, for panel A, the vertical line is at X = 22, which is the accepted normal value for radial inclination). ADL indicates activities of daily living; MHQ, Michigan Hand Outcomes Questionnaire.