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No Simple Fix for Wrist Fracture in Older Adults

January 24, 2019

By Marilynn Larkin

NEW YORK (Reuters Health) - Distal radius fracture treatment for older adults should depend on the individual's goals and the method's complication risks, researchers say.

The WRIST trial is the largest in hand surgery history, consisting of 24 hand centers from the U.S. and internationally. Researchers collected data on complications in patients 60 years of age and older treated with four standard treatments for distal radius fractures.

"Presenting the complication profiles of each treatment can guide the decision-making process not only from the surgeons' standpoint, but also help to assist patients in choosing the most appropriate treatments for their needs," Dr. Kevin Chung of the University of Michigan Medical School in Ann Arbor told Reuters Health by email.

Dr. Chung and colleagues conducted a secondary analysis of WRIST data for 296 participants who chose to undergo surgery or casting. Those opting for surgery were randomized to receive the volar locking plate system (VLPS), percutaneous pinning, or bridging external fixation with or without supplemental pinning. Those who did not want surgery were enrolled for casting.

As reported online January 18 in JAMA Network Open, randomized participants' mean age was 68, 87% were women, and 88% were white. Casting participants' mean age was 75.6, 84% were women, and 85% were white.

After taking crossovers into account, participants in the treated cohort included 74 in the VLPS group; 50 in pinning; 59 in external fixation; and 104 in casting.

The most common complications varied by treatment: 18.5% of participants in the internal fixation group reported a median nerve compression, whereas 25.8% of those who received external fixation and 23.2% who received pinning sustained pin site infections.

After adjustment for baseline covariates, compared with the VLPS group, rates of any complication remained significantly higher in the casting group (adjusted rate ratio, 1.88), and rates of moderate complications remained significantly higher in the external fixation group (aRR, 2.52).

There was no difference in rates of moderate or severe complications for pinning and casting compared with VLPS.

Dr. Chung noted additional factors that may affect treatment choice. "With improved surgical techniques, plate-related complications are rather infrequent; however, the cost of the plating system must be factored into the consideration of using plates in lieu of other less expensive treatments such wire or pins," he said.

"Treating with external hardware such as Kirchner wires or external fixators can introduce a burden to older adults because they are unable to clean the pins adequately without assistance," he noted. "Infections relating to the pins are common. If untreated, they can lead to serious infections that require hospitalization for intravenous antibiotics and premature removal of the hardware."

"The external fixator, which uses indirect methods of ligament distraction to achieve fracture reduction, has become an archaic technique because it is cumbersome to clean," he said. "This trial definitively showed that (it) is not an ideal treatment for distal radius fracture in the current era." While the cost is relatively low, "patients incurred the discomfort of external prominent hardware and potential pin infections."

For those who had casting, "osteoporotic bones led to collapse of the fractures, resulting in malunion," Dr. Chung said. "However, older patients do accept these deformities quite well."

Dr. Scott Levin of the University of Pennsylvania, President of the American Society for Surgery of the Hand and author of a related editorial, commented, "I have been looking forward to reviewing the data since the inception of the WRIST 2012."

This "landmark study" provides evidence that "each treatment is associated with certain complication profile that the patients need to understand and must discuss with the surgeon," he said in an email to Reuters Health.

"This kind of study most likely will not be done again because of the rigor it requires," he added. "I look forward to more publications from the WRIST trial to establish guiding principles on the treatment of distal radius fractures in older adults."


JAMA Netw Open 2019.

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