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NIHR Signal Using wires to fix wrist fracture has good long-term outcome

Published on 18 March 2020

doi: 10.3310/signal-000891

Fixing a displaced broken wrist with wires is as effective as fixation with locking plates in the long term. Wrist function and pain continue to improve in the five years following either operation, with no evidence of a difference between the two treatments.

In 2014, a trial comparing the use of Kirschner wires and locking plates for displaced fractures of the distal radius reported that patients treated with either operation did equally well after 12 months. This follow-up study allays fears that one year might have been too soon to rule out long-term problems.

The study validates the switch in NHS clinical practice towards wire fixation, where wires are inserted through the skin, from the more expensive locking plate procedure, where an incision is needed on the underside of the wrist to insert and screw the plate in place.

People having wire fixation can be reassured that they can expect a good recovery and that their wrist is likely to continue to improve during the subsequent five years.

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Why was this study needed?

It is estimated that 6% of women will have had a distal radius fracture by the time they are 80, with some requiring surgery where the fracture is displaced.

In 2014, most patients in the NHS needing surgical fixation of a displaced fracture of the distal radius were treated with locking plate fixation, in line with practice at the time. Practice changed rapidly after the publication of the initial 12-month results of this trial which showed that the less expensive Kirschner wire fixation method was equally effective. At the time, concerns from surgeons included the fear that wire fixation could lead to arthritic damage in the wrist joint and that this could occur more than 12 months after the operation.

This five-year follow-up study tracked the progress of patients to see whether pain and function differed in the long term.

What did this study do?

In the original randomised control trial, 461 patients whose surgeons believed they needed surgical fixation of their wrist fracture were randomised to either Kirschner wire fixation or locking plate fixation. Patients who needed open reduction of the fracture, where an incision had to be made to realign the bones, were excluded as Kirschner wires would not have been suitable.

After 12 months, patients were asked if they would take part in long-term follow-up and 301 agreed. They were sent annual questionnaires to assess pain and function of their wrist: the patient-rated wrist evaluation (PRWE) and the health-related quality of life (EQ-5D). They were also asked if there had been any further surgery on their wrist.

At year two, 294 participants provided scores, but data was only available on 198 by year five. This is a limitation, but there was no evidence of differential loss to follow-up. Results were analysed by treatment received, not treatment allocated at randomisation.

What did it find?

  • Wrist pain and function did not differ by treatment group at any point during five years’ follow-up. PWRE scores (0 to 100 with higher scores worse) reduced over time, showing improvement in pain and function, from a mean of 15.1 in year one to 8.3 in year five for the wire group, and 14.1 in year one to 11.3 in year five for the locking plate group.
  • The adjusted mean difference (aMD) in PRWE score was 1.06 (95% confidence interval [CI] -2.19 to 4.31) after one year and -2.91 (95% CI -6.91 to 1.08) after five years. The clinically important difference is six. Therefore, this difference is neither clinically nor statistically significant.
  • Quality of life did not differ by treatment group at any point during follow-up. On the EQ-5D scale (0 death, 1 perfect health) the wire group scored on average 0.89 versus 0.84 for the locking plate group at five years.
  • Only three participants needed additional surgery during the follow-up period: one in the wire group and two in the locking plate group.

What does current guidance say on this issue?

The British Society for Surgery of the Hand (BSSH) guideline published in 2018 does not recommend locking plate fixation for adults with a displaced fracture of the distal radius.

The guideline recommends: “When surgery is needed for dorsally displaced DRFs [distal radial fractures] that can be reduced closed, offer K-wire fixation and cast.” Use of locking-plate fixation is not mentioned in this section of the guideline.

What are the implications?

The study findings support the move away from locking plate to wire fixation of this type of fracture, demonstrating that the long-term outcomes are at least as good as the 12-month outcome that prompted the initial management shift.

Surgeons choosing wire fixation can reassure patients that they are likely to have a successful outcome and that their wrist function should continue to improve for several years after the operation.

Citation and Funding

Costa ML, Achten J, Rangan A, Lamb SE, Parsons NR. Percutaneous fixation with Kirschner wires versus volar locking-plate fixation in adults with dorsally displaced fracture of distal radius: five-year follow-up of a randomized controlled trial. Bone Joint J. 2019;101-B(8):978–83.

The project was funded by the NIHR Health Technology Assessment Programme (project numbers 08/116/97 and 15/143/02).

Bibliography

Costa ML, Achten J, Parsons NR et al. Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of distal radius: randomised controlled trial. BMJ. 2014;349:g4807.

BSSH. Best practice for management of distal radial fractures. London: British Society for Surgery of the Hand and British Orthopaedic Association; 2018.

Why was this study needed?

It is estimated that 6% of women will have had a distal radius fracture by the time they are 80, with some requiring surgery where the fracture is displaced.

In 2014, most patients in the NHS needing surgical fixation of a displaced fracture of the distal radius were treated with locking plate fixation, in line with practice at the time. Practice changed rapidly after the publication of the initial 12-month results of this trial which showed that the less expensive Kirschner wire fixation method was equally effective. At the time, concerns from surgeons included the fear that wire fixation could lead to arthritic damage in the wrist joint and that this could occur more than 12 months after the operation.

This five-year follow-up study tracked the progress of patients to see whether pain and function differed in the long term.

What did this study do?

In the original randomised control trial, 461 patients whose surgeons believed they needed surgical fixation of their wrist fracture were randomised to either Kirschner wire fixation or locking plate fixation. Patients who needed open reduction of the fracture, where an incision had to be made to realign the bones, were excluded as Kirschner wires would not have been suitable.

After 12 months, patients were asked if they would take part in long-term follow-up and 301 agreed. They were sent annual questionnaires to assess pain and function of their wrist: the patient-rated wrist evaluation (PRWE) and the health-related quality of life (EQ-5D). They were also asked if there had been any further surgery on their wrist.

At year two, 294 participants provided scores, but data was only available on 198 by year five. This is a limitation, but there was no evidence of differential loss to follow-up. Results were analysed by treatment received, not treatment allocated at randomisation.

What did it find?

  • Wrist pain and function did not differ by treatment group at any point during five years’ follow-up. PWRE scores (0 to 100 with higher scores worse) reduced over time, showing improvement in pain and function, from a mean of 15.1 in year one to 8.3 in year five for the wire group, and 14.1 in year one to 11.3 in year five for the locking plate group.
  • The adjusted mean difference (aMD) in PRWE score was 1.06 (95% confidence interval [CI] -2.19 to 4.31) after one year and -2.91 (95% CI -6.91 to 1.08) after five years. The clinically important difference is six. Therefore, this difference is neither clinically nor statistically significant.
  • Quality of life did not differ by treatment group at any point during follow-up. On the EQ-5D scale (0 death, 1 perfect health) the wire group scored on average 0.89 versus 0.84 for the locking plate group at five years.
  • Only three participants needed additional surgery during the follow-up period: one in the wire group and two in the locking plate group.

What does current guidance say on this issue?

The British Society for Surgery of the Hand (BSSH) guideline published in 2018 does not recommend locking plate fixation for adults with a displaced fracture of the distal radius.

The guideline recommends: “When surgery is needed for dorsally displaced DRFs [distal radial fractures] that can be reduced closed, offer K-wire fixation and cast.” Use of locking-plate fixation is not mentioned in this section of the guideline.

What are the implications?

The study findings support the move away from locking plate to wire fixation of this type of fracture, demonstrating that the long-term outcomes are at least as good as the 12-month outcome that prompted the initial management shift.

Surgeons choosing wire fixation can reassure patients that they are likely to have a successful outcome and that their wrist function should continue to improve for several years after the operation.

Citation and Funding

Costa ML, Achten J, Rangan A, Lamb SE, Parsons NR. Percutaneous fixation with Kirschner wires versus volar locking-plate fixation in adults with dorsally displaced fracture of distal radius: five-year follow-up of a randomized controlled trial. Bone Joint J. 2019;101-B(8):978–83.

The project was funded by the NIHR Health Technology Assessment Programme (project numbers 08/116/97 and 15/143/02).

Bibliography

Costa ML, Achten J, Parsons NR et al. Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of distal radius: randomised controlled trial. BMJ. 2014;349:g4807.

BSSH. Best practice for management of distal radial fractures. London: British Society for Surgery of the Hand and British Orthopaedic Association; 2018.

Percutaneous fixation with Kirschner wires versus volar locking-plate fixation in adults with dorsally displaced fracture of distalradius: five-year follow-up of a randomized controlled trial

Published on 1 August 2019

Costa ML; Achten J; Rangan A; Lamb SE; Parsons NR.

Bone and Joint Journal Volume 101-B , 2019

Aims The aim of this study was to compare the clinical effectiveness of Kirschner wire (K-wire) fixation with locking-plate fixation for patients with a dorsally displaced fracture of the distal radius in the five years after injury. Patients and Methods We report the five-year follow-up of a multicentre, two-arm, parallel-group randomized controlled trial. A total of 461 adults with a dorsally displaced fracture of the distal radius within 3 cm of the radiocarpal joint that required surgical fixation were recruited from 18 trauma centres in the United Kingdom. Patients were excluded if the surface of the wrist joint was so badly displaced it required open reduction. In all, 448 patients were randomized to receive either K-wire fixation or locking-plate fixation. In the K-wire group, there were 179 female and 38 male patients with a mean age of 59.1 years (19 to 89). In the locking-plate group, there were 194 female and 37 male patients with a mean age of 58.3 years (20 to 89). The primary outcome measure was the patient-rated wrist evaluation (PRWE). Secondary outcomes were health-related quality of life using the EuroQol five-dimension three-level (EQ-5D-3L) assessment, and further surgery related to the index fracture. Results At 12 months, 402/448 participants (90%) recruited into the main study provided PRWE scores. At year two, 294 participants (66%) provided scores; at year five, 198 participants (44%) provided scores. There was no clinically relevant difference in the PRWE at any point during the five-year follow-up; at five years, the PRWE score was 8.3 (12.5) in the wire group and 11.3 (15.6) in the plate group (95% confidence interval -6.99 to 0.99; p = 0.139). Nor was there a clinically relevant difference in health-related quality of life. Only three participants had further surgery in the five years after their injury (one in the wire group and two in the plate group). Conclusion This follow-up study continues to show no evidence of a difference in wrist pain, wrist function, or quality of life for patients treated with wires versus locking plates in the five years following a dorsally displaced fracture of the distal radius.

Expert commentary

Percutaneous K-wire fixation and volar locking plates are two of the most commonly used surgical treatments for unstable dorsally displaced distal radius fractures. Distal radius fractures are still common and are increasing in incidence. Despite our better understanding of biomechanics, numerous classifications and a huge body of published data, the most effective treatment is still unclear.

This paper is the five-year follow-up of a similar study which was published in 2014. This randomised controlled study showed no evidence of a difference in wrist pain, wrist function, or quality of life for patients treated with K-wires versus locking plates in the five years following a dorsally displaced fracture of the distal radius.

It also reassures the treating surgeon and the patients that their wrist function is likely to continue to improve in the five years following their injury and most patients can expect very good function with little pain from their wrist, albeit not quite back to their pre-injury level.

Behrooz Mostofi, Professor in Orthopaedics, Consultant Orthopaedic Surgeon, East Kent Hospital University NHS Foundation Trust

The commentator declares no conflicting interests