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Volar Locking Plate May Outperform Conservative Treatment of Distal Radius Fracture in Older Patients

Key findings

  • This systematic review and network meta-analysis examined 14 randomized, controlled trials of four treatment approaches to distal radius fractures in patients 60 and older (n=1,376), focusing on the primary outcomes of grip strength and complications
  • Volar locking plate fixation (VLP) was associated with better grip strength than conservative treatment both at one-year and minimum two-year follow-up
  • The number of complications did not differ between the four treatment approaches: conservative treatment, VLP, K-wire fixation, and external fixation
  • Of the four treatment approaches, VLP ranked highest concerning grip strength at one-year follow-up, grip strength at minimum two-year follow-up and complication rate, and external fixation ranked last on those outcome measures
  • In a subgroup analysis of trials in which the mean age was between 60 and 80, VLP was associated with better grip strength than conservative treatment, and VLP and K-wire fixation were linked to better scores on patient-related outcome measures

Meta-analyses comparing non-operative and surgical treatment of distal radius fractures have shown no clinically significant differences in patient-related outcome measures (PROMs). However, PROMs are strongly influenced by psychosocial factors, which have not been well controlled for, and among older patients, there have been wide confidence intervals in the results.

In a systematic review and network meta-analysis that compared operative and non-operative approaches, researchers at Massachusetts General Hospital used grip strength as a primary outcome. Besides being an objective indicator of hand function, grip strength has been correlated with mortality, cardiovascular death, and cognitive function.

The team concludes in Injury that, among patients 60 years and older who had distal radius fractures, volar locking plate fixation (VLP) provided better grip strength than conservative treatment, with no greater complication rate. The authors are Oscar Shen, MBChB, a research fellow in the Hand and Arm Service in the Department of Orthopaedic Surgery, Neal C. Chen, MD, chief of the Service, Wen-Chih Liu, MD, a visiting scholar, and colleagues.


On October 19, 2022, the researchers searched PubMed, EMBASE, and Web of Science for randomized, controlled trials that enrolled only patients 60 years and older, compared at least two of four prespecified interventions for distal radius fractures and followed patients for at least one year.

They identified 14 trials (n=1,376 patients, mean age: 74). Conservative treatment was examined in 13 trials, VLP in 11, K-wire fixation in four, and external fixation in three.

Primary Outcomes

Grip strength was superior with VLP when compared with conservative therapy:

  • At 1 year—standardized mean difference (SMD), 0.28
  • At ≥2 years—SMD, 0.27

These SMDs correspond to a small to medium effect. The number of complications did not differ between the four types of treatment.

Hierarchy of Treatments

The team also calculated the surface under the cumulative ranking curve (SUCRA). A large SUCRA value meant the treatment was more likely to be effective and less likely to be associated with complications:

  • Grip strength at 1 year—VLP (SUCRA=90%) ranked first and external fixation (SUCRA=8%) ranked last
  • Grip strength at ≥2 years—VLP (SUCRA=87%) ranked first and external fixation (SUCRA=10%) ranked last
  • Complications—VLP was associated with the fewest (SUCRA=84%) and external fixation the most (SUCRA=5%)

The results were similar in a cluster analysis that grouped treatments based on SUCRA values.

Subgroup Analysis

Advanced age may be a confounder for grip strength, and indications for surgery may be different in patients older than 80 years. The researchers, therefore, conducted a subgroup analysis of the 13 trials in which the mean age was between 60 and 80 years old.

Once again, grip strength was better with VLP than conservative treatment:

  • At 1 year—SMD, 0.39
  • At ≥2 years—SMD, 0.27

VLP (SMD, 0.33) and especially K-wire fixation (SMD, 0.82) outperformed conservative treatment based on DASH scores (Disabilities of the Arm, Shoulder, and Hand). VLP also outperformed conservative treatment based on PRWE scores (Patient-Rated Wrist Evaluation) (SMD, 0.23).

Putting the Findings in Context

Practice guidelines of the American Academy of Orthopaedic Surgeons and the Standards for Practice of the British Orthopaedic Association don't support internal fixation for distal radius fractures in older patients. However, this study shows VLP may provide a meaningful benefit.

K-wire fixation may perform similarly to VLP if patients are reasonable candidates, such as those with extra-articular fractures and adequate bone density.

Learn more about the Hand Surgery Clinical Research Unit at Mass General

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