Unstable distal radial fractures treated with external fixation, a radial column plate, or a volar plate. A prospective randomized trial.

BACKGROUND Optimal surgical management of unstable distal radial fractures is controversial, and evidence from rigorous comparative trials is rare. We compared the functional outcomes of treatment of unstable distal radial fractures with external fixation, a volar plate, or a radial column plate. METHODS Forty-six patients with an injury to a single limb were randomized to be treated with augmented external fixation (twenty-two patients), a locked volar plate (twelve), or a locked radial column plate (twelve). The fracture classifications included Orthopaedic Trauma Association (OTA) types A3, C1, C2, and C3. The patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire at the time of follow-up. Grip and lateral pinch strength, the ranges of motion of the wrist and forearm, and radiographic parameters were also evaluated. RESULTS At six weeks, the mean DASH score for the patients with a volar plate was significantly better than that for the patients treated with external fixation (p = 0.037) but similar to that for the patients with a radial column plate (p = 0.33). At three months, the patients with a volar plate demonstrated a DASH score that was significantly better than that for both the patients treated with external fixation (p = 0.028) and those with a radial column plate (p = 0.027). By six months and one year, all three groups had DASH scores comparable with those for the normal population. At one year, grip strength was similar among the three groups. The lateral pinch strength of the patients with a volar plate was significantly better than that of the patients with a radial column plate at three months (p = 0.042) and one year (p = 0.036), but no other significant differences in lateral pinch strength were found among the three groups at the other follow-up periods. The range of motion of the wrist did not differ significantly among the groups at any time beginning twelve weeks after the surgery. At one year, the patients with a radial column plate had maintained radial inclination and radial length that were significantly better than these measurements in both the patients treated with external fixation and those with a volar plate (all p < 0.05). CONCLUSIONS Use of a locked volar plate predictably leads to better patient-reported outcomes (DASH scores) in the first three months after fixation. However, at six months and one year, the outcomes of all three techniques evaluated in this study were found to be excellent, with minimal differences among them in terms of strength, motion, and radiographic alignment.