Does Grandma Need Surgery for That Broken Wrist?
Patient-reported outcomes 2 years after treatment for distal wrist fractures didn't differ significantly in older patients irrespective of the therapy chosen, including simple casting, a randomized trial showed. That was true even for participants who chose casting and experienced malunion during recovery with visible, permanent deformity, according to Kevin C. Chung, MD, MS, of the University of Michigan in Ann Arbor, and colleagues, writing in JAMA Network Open. Given the risks associated with surgery and other skin-piercing interventions, the results suggest that casting may be preferable for most cases -- as long as patients "understand the ramification of malunion and observed wrist deformity," Chung's group cautioned. The bottom line, they concluded, is that long-term outcomes should not be the deciding factor in choosing the right approach in individual cases, as they were the same for surgical interventions, pinning, or casting in the 304-patient Wrist and Radius Injury Surgical Trial (WRIST). The study tested four approaches in patients ages 60 and older suffering distal wrist fractures severe enough to be considered for surgery but otherwise uncomplicated. Patients were asked if they were willing to undergo relatively aggressive interventions; those assenting (n=187) were randomized 1:1:1 to open surgery to perform internal fixation with a volar locking plate system; external fixation with a bridging device, in some cases with supplemental wire fixation; or percutaneous pinning. Participants not wanting any of these (n=117) underwent closed reduction and casting. Mean patient age was about 70 in the surgical groups and 73 in those preferring conservative management. About 80% of participants were white. Nearly three-quarters of the casting group reported being sedentary or underactive prior to injury, compared with about half of those consenting to surgery. Chung and colleagues evaluated outcomes at 12 and 24 months with a number of instruments: the patient-completed Michigan Hand Outcomes Questionnaire, a 36-item medical outcomes survey, eight objective measures of function (e.g., grip strength, forearm bone deviation), and patient-reported changes in physical activity from pre-injury levels. "Malunion was defined as dorsal or volar tilt greater than 10 from neutral, radial inclination less than 15, or radial shortening greater than 3 mm," the researchers explained. In fact, malunion was seen in 42 patients, including 26 in the casting group. Other than that and an associated higher rate of ulnar deviation, however, no significant differences were seen among the four WRIST groups in any outcome measure at 24 months. Some nonsignificant trends suggested that the casting group had fared worse, but differences in point estimates were not clinically significant either, the researchers said. Notably, 60% of the patients choosing conservative management didn't show up for the 24-month evaluation (vs 26% of those in the surgical groups), but Chung and colleagues argued that these losses to follow-up don't necessarily detract from the study's results or lead to overestimating benefits from casting. "[P]atients who did not return for 24-month assessments may have done so because they were satisfied with their recovery, thus underestimating 12- to 24-month improvements," the researchers wrote. As well, they added, "similar profiles in mean [Michigan Hand Questionnaire] summary scores over time across missing data patterns within each treatment groups suggest no evidence for biases." In an accompanying commentary, Jason Michael Johanning, MD, MS, of the University of Nebraska Medical Center in Omaha, largely agreed with the group's conclusions and expressed no concerns about the study's limitations. "The ultimate take-home message for our patients now is a clear-cut benefit of nonoperative management for patients with distal radius fracture with outcomes equivalent to those of alternative invasive modalities for a substantial number of patients," he wrote. Johanning noted that complication rates from wrist fracture surgery have previously been reported to be about 15-20% (short-term surgical complications weren't addressed by Chung's group). "In the highly functional patient with an active lifestyle, casting still remains an attractive option, with patients counseled that both radiographic and outward appearances do not correlate with functional outcome." But that's not to say that all wrist fractures in the elderly should be managed conservatively, Johanning stressed. "According to the literature, there will be a subset of patients, with findings including greater than 20 of dorsal angulation, 5 mm of radial shortening, dorsal comminution, ulna fracture, or intra-articular radiocarpal involvement, who may ultimately benefit from surgical intervention."