Distal Radial Fractures
In a prospective randomized trial, Martinez-Mendez et al. compared volar plate fixation and cast management in patients who were >60 years of age and had AO type-C distal radial fractures1. At the time of the final follow-up, at least 24 months after the injury, the primary outcome measure (Patient-Rated Wrist Evaluation total score) was lower (indicating less disability) in the group randomized to volar plating. There were no losses of reduction in the volar plating group, but loss of reduction did occur in 26% (12 of 47) of the patients in the casting group. This Level-I evidence of superior patient-reported outcomes with volar plating for patients who were ≥60 years of age is contrary to a prior Level-I study conducted in Austria by Arora et al. published in The Journal of Bone and Joint Surgery (American volume) in 20112. There are interesting contrasts between the 2 studies: Arora et al. included patients who were ≥65 years of age and also included both AO type-A and type-C fractures. Interestingly, the mean Patient-Rated Wrist Evaluation scores reported at 12 months in both the volar plating group (12.8 points) and the casting group (14.6 points) in the study by Arora et al. were lower than those reported in both the volar plating group (17 points) and the casting group (30 points) in the study by Martinez-Mendez et al. at ≥24 months, suggesting that there are patient-level and surgeon-level differences between the 2 environments in which the studies were conducted. Baseline activity levels were not assessed in either study, with age and radiographic criteria used to determine eligibility; however, bias from differences in baseline activity was likely to have been accounted for in randomization.

Based on recent literature, many surgeons treat distal radial fractures in elderly patients with cast management, regardless of fracture appearance on radiographs. In many cases, both the surgeon and the patient expect a malunion that is unlikely to impede function. More information about the prevalence and natural history of these anticipated malunions can aid in patient counseling. Wadsten et al.3 examined 175 patients with distal radial fractures treated nonoperatively who had 3-month radiographic follow-up and 1-year clinical follow-up. Only patients with a radiographically acceptable reduction at 1 to 2 weeks were included in the study. At the 3-month follow-up, 28% of patients had late displacement or malunion. Cases with late displacement or malunion had lower grip strength and a loss of the total wrist range of motion. However, there was no difference in patient-reported functional measures between late displacement or malunion and non-malunion groups. The most common complication was carpal tunnel syndrome, occurring in 19% of the overall cohort (with no difference between the 2 groups).

Concerns remain with regard to potential complications involving extensor and flexor tendons after volar plating. In a prospective evaluation of patients with unicortical fixation in the distal row, Dardas et al. demonstrated that this strategy can effectively maintain reduction, with only 2 cases (of 75 total cases) with loss of reduction4. There were no cases of extensor tendon rupture or extensor tenosynovitis. The positioning of the volar plate relative to the watershed line is often discussed as a risk factor for flexor tendon irritation. In a cadaveric study, Wurtzel et al. demonstrated that increased contact between the flexor plexus longus and the volar plate is dependent not only on the position of the plate, but also on the residual sagittal angulation (maintenance or loss of volar tilt)5. With a distally positioned plate and a neutral volar tilt, contact between the flexor plexus longus and the volar plate occurred at approximately 45° of wrist extension. Contact between the flexor pollicis longus and the volar plate occurs at even lower amounts of wrist extension when there is a dorsal malunion, suggesting that surgeons should closely monitor for flexor plexus longus irritation as patients recover wrist flexion if the volar plate has been placed distally and/or if anatomic volar tilt has not been restored.