Plates not better than K-wires in distal radius fractures?

 Kirschner wire fixation is a longstanding technique in which smooth metal wires with a sharp point are passed across the fracture site through the skin. This technique is rapidly being superseded by locking plate fixation, in which a plate is attached to the bone with fixed angle screws. Locking plates are widely considered to provide stronger fixation, which facilitates earlier return to normal activities. This potential benefit is said to justify the greater cost of the plates.To date, studies comparing the two methods have indicated that locking plates provide improved radiological and/or functional outcomes, particularly in the early stages of rehabilitation; though these studies were smaller single centre trials.

In this multicentre randomised trial, the distal radius acute fracture fixation trial (DRAFFT), the authors examined Kirschner wire fixation compared with volar locking plate fixation for patients with a dorsally displaced fracture of the distal radius. The hypothesis was that locking plates would provide improvements in the patient rated wrist evaluation (PRWE) score in the 12 months after surgery.

Objectives To compare the clinical effectiveness of Kirschner wire fixation with locking plate fixation for patients with a dorsally displaced fracture of the distal radius.

Design A multicentre two arm parallel group assessor blind randomised controlled trial with 1:1 treatment allocation.

Setting 18 trauma centres in the United Kingdom.

Participants 461 adults with a dorsally displaced fracture of the distal radius within 3 cm of the radiocarpal joint that required surgical fixation. Patients were excluded if the surgeon thought that the surface of the wrist joint was so badly displaced it required open reduction.

Interventions Kirschner wire fixation: wires are passed through the skin over the dorsal aspect of the distal radius and into the bone to hold the fracture in the correct anatomical position. Locking plate fixation: a locking plate is applied through an incision over the volar (palm) aspect of the wrist and secured to the bone with fixed angle locking screws.

Main outcome measures Primary outcome measure: validated patient rated wrist evaluation (PRWE). This rates wrist function in two (equally weighted) sections concerning the patient’s experience of pain and disability to give a score out of 100. Secondary outcomes: disabilities of arm, shoulder, and hand (DASH) score, the EuroQol (EQ-5D), and complications related to the surgery.

Results The baseline characteristics of the two groups were well balanced, and over 90% of patients completed follow-up. The wrist function of both groups of patients improved by 12 months. There was no clinically relevant difference in the patient rated wrist score at three, six, or 12 months (difference in favour of the plate group was −1.3, 95% confidence interval −4.5 to 1.8; P=0.40). Nor was there a clinically relevant difference in health related quality of life or the number of complications in each group.

Conclusions Contrary to the existing literature, and against the rapidly increasing use of locking plate fixation, this trial found no difference in functional outcome in patients with dorsally displaced fractures of the distal radius treated with Kirschner wires or volar locking plates. Kirschner wire fixation, however, is cheaper and quicker to perform.

 Dr Pietsch, distal radius fractures, treatment of radius fractures, K-wires in radius fractures, theexpertwitnessreference.blogspot.com

 Literature:

 BMJ 2014;349:g4807