Surgical treatment may be associated with better 1-year patient-reported outcomes compared with nonsurgical management in patients with distal radius fractures classified as Arbeitsgemeinschaft fur Osteosynthesefragen 23-C2 and 23-C3, according to a national Swedish cohort study. The association was observed primarily in comminuted intra-articular fracture patterns, whereas other distal radius fracture subtypes showed little or no clinically meaningful benefit with surgery.
In the study, investigators analyzed data from the Swedish Fracture Register collected from 2013 to 2018 across 36 hospitals. They included 13,356 distal radius fractures in 13,031 patients aged 18 years or older. Fractures included those classified as Arbeitsgemeinschaft fur Osteosynthesefragen (AO) 23-A2.1, 23-A2.2, 23-A3, 23-C1, 23-C2, and 23-C3, with those in the A group representing extra-articular fractures and those in the C group representing intra-articular fractures. To reduce treatment-selection bias, the investigators conducted an instrumental variable analysis based on differences in annual hospital surgical rates, treating variation in surgical treatment across the hospitals as a random treatment assignment and natural experiment.
The primary outcome was the Arm and Hand Function Index from the Short Musculoskeletal Function Assessment (SMFA) measured 1 year postinjury. Secondary outcomes included additional SMFA indices and EuroQol Group 5–Dimension measures. Lower SMFA scores reflected better function.
Across all fracture types, surgery was associated with an average 6.2-point lower Arm and Hand Function Index score compared with nonsurgical treatment, a difference below the study’s threshold for minimal clinically important difference. However, subgroup analyses showed larger improvements in more severe intra-articular fractures. For instance, surgical treatment was associated with an 11.9-point lower score in AO 23-C2 fractures and a 19.4-point lower score in AO 23-C3 fractures. Both differences exceeded the study’s prespecified threshold for clinically meaningful improvement.
Patients with dorsally angulated extra-articular fractures (AO 23-A2.2) showed a trend toward improved outcomes with surgery, although the difference did not meet thresholds for minimal clinically important difference. The investigators reported no statistically significant benefit with surgery in other extra-articular fractures or in simple intra-articular (AO 23-C1) fractures.
Secondary analyses generally supported the primary findings. In patients with AO 23-C2 and -C3 fractures, surgery was also associated with improved patient-reported outcomes on the SMFA Function and SMFA Bother indices and on the EuroQol Group 5–Dimension Index. EuroQol visual analogue scale scores did not differ significantly between the treatment groups. Sensitivity analyses excluding patients with associated injuries, bilateral fractures, delayed surgery following failed conservative treatment, or interhospital referral transfers produced similar findings.
The investigators noted several limitations. The study was observational and relied on assumptions underlying the instrumental variable approach, including that hospitals treated similar fracture populations over time. The registry did not include radiographic details such as fracture displacement, and the response rate for patient-reported outcomes was 40%. The investigators also noted that computed tomography use may have varied across hospitals and could have influenced fracture classification.
"Our study did not support an increased tendency to treat other [distal radial] fracture types surgically within the surgical rate ranges reported," wrote lead study author Albert Christersson, of the Department of Surgical Sciences at Uppsala University, and colleagues. They added that “a more rigorous selection process for nonsurgical treatment should be adopted" in AO 23-C2 and -C3 fractures.
The study authors reported no competing interests. No external funding was received for the study.
Source: BMC Musculoskeletal Disorders
