Mateusz Gładysz FESSH prep

FESSH prep Wrist trauma AO type B partial articular patterns, Mackenney's predictors of instability, DRAFFT and DRAFFT2, operative versus non operative treatment in older patients

Distal radius fractures: classification, instability and fixation evidence

Last reviewed v2.0

FESSH-045Wrist trauma●○○ basic

Regarding fractures of the distal radius:

  1. 1.In the AO (Müller) classification, partial-articular type B fractures are subdivided into radial styloid (B1, chauffeur's), dorsal rim (B2) and volar rim (B3, volar Barton's) patterns.

  2. 2.In Mackenney's prospective study of about 4,000 distal radial fractures, patient age, metaphyseal comminution and ulnar variance were the most consistent predictors of radiographic outcome (instability and malunion), whereas dorsal angulation did not predict the outcome of displaced fractures.

  3. 3.In the DRAFFT trial, Kirschner-wire fixation and volar locking-plate fixation of dorsally displaced distal radius fractures gave no clinically relevant difference in the Patient-Rated Wrist Evaluation at 12 months, and no clinically relevant difference was found at five years.

  4. 4.DRAFFT2 showed that K-wire fixation improves wrist function at 12 months compared with a moulded cast after manipulation of a dorsally displaced distal radius fracture.

  5. 5.Meta-analyses show a clinically important functional benefit of volar locking-plate fixation over cast treatment in patients aged 60 years and over.

FESSH marking: +1 per correct statement, 0 for blank, −1 for incorrect. Click the same TRUE/FALSE button twice to clear it.

Question ID
FESSH-045
First published
Last reviewed
Version
v2.0
Answer key and explanations — open after answering

  1. 1. In the AO (Müller) classification, partial-articular type B fractures are subdivided into radial styloid (B1, chauffeur's), dorsal rim (B2) and volar rim (B3, volar Barton's) patterns.

    True

    The comprehensive classification of Müller and colleagues defines shearing injuries that involve part of the articular surface as type B: B1 involves the radial styloid (the chauffeur's fracture), B2 the dorsal margin and B3 the volar margin of the distal radius (Barton's fracture). Type B fractures are unstable and often need operative fixation, whereas compression injuries of the whole articular surface are type C — C1 two-part without metaphyseal comminution, C2 two-part with comminution and C3 multifragmentary.

    • Jupiter JB. Complex Articular Fractures of the Distal Radius: Classification and Management. J Am Acad Orthop Surg. 1997;5(3):119-129. PMID 10797214

  2. 2. In Mackenney's prospective study of about 4,000 distal radial fractures, patient age, metaphyseal comminution and ulnar variance were the most consistent predictors of radiographic outcome (instability and malunion), whereas dorsal angulation did not predict the outcome of displaced fractures.

    True

    Data on approximately 4,000 fractures recorded prospectively over 5.5 years were analysed by logistic regression for early and late instability, malunion and carpal malalignment at six weeks. Patient age, metaphyseal comminution and ulnar variance were the most consistent predictors of radiographic outcome; dorsal angulation was not significant for displaced fractures, and the patient's level of independence predicted malunion. The authors derived predictive formulas for each radiographic outcome but cautioned that they need validation before guiding treatment.

    • Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am. 2006;88(9):1944-51. PMID 16951109

  3. 3. In the DRAFFT trial, Kirschner-wire fixation and volar locking-plate fixation of dorsally displaced distal radius fractures gave no clinically relevant difference in the Patient-Rated Wrist Evaluation at 12 months, and no clinically relevant difference was found at five years.

    True

    DRAFFT randomised 461 adults in 18 UK centres with a dorsally displaced fracture within 3 cm of the radiocarpal joint that needed fixation (fractures needing open articular reduction were excluded). Wrist function improved in both groups by 12 months with no clinically relevant difference in PRWE at three, six or 12 months (difference −1.3 in favour of the plate, 95 % CI −4.5 to 1.8), in quality of life or in complications; wire fixation was cheaper and quicker. At five years the PRWE was 8.3 after wires and 11.3 after plates (95 % CI −6.99 to 0.99), with only three further operations in the whole cohort.

    • Costa ML, Achten J, Parsons NR, Rangan A, Griffin D, Tubeuf S, et al.. Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of distal radius: randomised controlled trial. BMJ. 2014;349:g4807. PMID 25096595
    • Costa ML, Achten J, Rangan A, Lamb SE, Parsons NR. Percutaneous fixation with Kirschner wires versus volar locking-plate fixation in adults with dorsally displaced fracture of distal radius: five-year follow-up of a randomized controlled trial. Bone Joint J. 2019;101-B(8):978-983. PMID 31362548

  4. 4. DRAFFT2 showed that K-wire fixation improves wrist function at 12 months compared with a moulded cast after manipulation of a dorsally displaced distal radius fracture.

    False

    DRAFFT2 randomised 500 adults (mean age 60) after manipulation to a moulded cast or K-wire fixation plus cast in 36 NHS hospitals. The 12-month PRWE did not differ (21.2 versus 20.7; adjusted difference −0.34, 95 % CI −4.33 to 3.66), nor did the earlier scores or quality of life. The price of casting was a second procedure: 33 patients (13 %) in the cast group needed surgical fixation for loss of position within six weeks, against one revision after K-wires — so casting is a reasonable first choice if the patient accepts that risk and is followed radiographically.

    • Costa ML, Achten J, Ooms A, Png ME, Cook JA, Lamb SE, et al.. Surgical fixation with K-wires versus casting in adults with fracture of distal radius: DRAFFT2 multicentre randomised clinical trial. BMJ. 2022;376:e068041. PMID 35045969

  5. 5. Meta-analyses show a clinically important functional benefit of volar locking-plate fixation over cast treatment in patients aged 60 years and over.

    False

    In the pooled analysis by Ochen and colleagues (23 studies, 2,254 patients) operative treatment improved the medium-term DASH score by 5.2 points overall — below the 10-point minimal clinically important difference — and in the subgroup restricted to patients aged 60 and over there was no improvement at all (−0.98 points) and complications were more frequent after operation (risk ratio 1.51, 95 % CI 1.15 to 2.00); the better grip strength and the equal complication rate apply to the all-ages analysis. Lawson's meta-analysis of eight randomised trials found a 4.1-point DASH difference at 12 months in favour of plating, again well below clinical importance, with better alignment but not better function; in Arora's trial of patients aged 65 and over the operative group had better grip and alignment, equal PRWE and DASH at 6 and 12 months, and more complications (13 versus 5).

    • Ochen Y, Peek J, van der Velde D, Beeres FJP, van Heijl M, Groenwold RHH, et al.. Operative vs Nonoperative Treatment of Distal Radius Fractures in Adults: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(4):e203497. PMID 32324239
    • Lawson A, Na M, Naylor JM, Lewin AM, Harris IA. Volar Locking Plate Fixation Versus Closed Reduction for Distal Radial Fractures in Adults: A Systematic Review and Meta-Analysis. JBJS Rev. 2021;9(1):e20.00022. PMID 33512973
    • Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011;93(23):2146-53. PMID 22159849