Volar locking plating slightly improves wrist function in older adults with DRF

The use of volar locking plating (VLP) for the operative treatment of primarily malaligned distal radius fracture (DRF) results in small improvements in wrist function at 12 months among older adults with DRF, reports a recent study.

“The estimated mean difference between the groups was, however, smaller than the predefined minimal clinically important difference (MCID) of the Patient Rated Wrist Evaluation (PRWE),” the investigators said. “In DRFs with early loss of alignment, operative treatment does not appear to provide benefit.”

This trial was carried out at five trauma centres in Finland, Sweden, and Denmark between 15 March 2018 and 6 June 2023, including 291 patients aged ≥65 years with a dorsally displaced AO-type A or C DRF. Of these, 258 were women.

The investigators randomized patients with DRF who did not maintain alignment after closed reduction (CR) to nonoperative treatment or VLP. Those with acceptable alignment after CR visited the outpatient clinic 5‒10 days after CR. If the alignment was lost, patients were then randomly assigned to either continue nonoperative treatment or VLP. The 12-month follow-up was completed on 11 June 2024.

Participants and orthopaedic investigators were not blinded, while statisticians and investigators responsible for the analysis remained blinded to the treatment groups during the data analysis and the drawing of conclusions.

A total of 124 DRFs did not maintain acceptable fracture alignment following CR, of which 66 were randomized to nonoperative treatment and 58 to VLP (primarily malaligned DRFs). Meanwhile, 86 patients lost alignment within 10 days of follow-up, of which 44 were randomly allocated to continue nonoperative treatment and 42 to VLP (early malaligned DRFs). [PLoS Med 2025;22:e1004728]

At 12 months, the estimated mean effect for PRWE in primarily malaligned DRFs was ‒9.6 points (95 percent confidence interval [CI], ‒17.4 to ‒1.7; p=0.0178), favouring VLP. However, this was smaller than the predefined MCID of the PRWE at 11 points. In early malaligned DRFs, the mean effect for PRWE was ‒6.2 points (95 percent CI, ‒15.4 to 3.0; p=0.1816).

Safety profile

Twenty-five treatment-related adverse events (AEs) were recorded over 12 months of follow-up: 10/66 (15 percent) in primarily malaligned DRFs nonoperative; 5/58 (8.6 percent) in primarily malaligned DRFs operative; 2/44 (4.5 percent) in early malaligned DRFs nonoperative; 3/42 (7.1 percent in early malaligned DRFs operative; 5/63 (6.9 percent) in well-aligned DRFs; and 11 other AEs.

“Our results suggest that the choice of treatment modality should be made following primary fracture reduction because subsequent monitoring of fracture alignment does not offer any additional benefit in terms of expected wrist function,” the investigators said. “This questions the need for early radiographic follow-up during the nonoperative treatment.”

Of note, the global COVID-19 pandemic caused the trial recruitment period to be longer than expected. Because of the reduced inclusion rate, the investigators had to stop recruiting patients with early malaligned DRF before reaching the predefined 57 patients per group. This was the main limitation of the study, according to the investigators.