(Editor’s Note: This post was sent to our Fractures/Trauma subscribers, and although some of our Hand subscribers also get the Fractures/Trauma newsletter, many do not, and some may have missed it. We thought this one too important for anyone who takes care of patients with wrist fractures to miss. Apologies to those of you who are getting it a second time. — SSL)
What’s the Claim?
A secondary analysis of a prior RCT (the Wrist and Radius Injury Surgical Trial (WRIST)) found active, older adults who had few comorbidities and who underwent ORIF with volar locking plates had less pain and earlier return to daily activities than patients treated with casting, both at 6 weeks and a year after injury. The study’s authors discovered that chronological age was a poor proxy for functional demand (activity level), and they measured functional demand directly, using a tool called the Rapid Assessment of Physical Activity (RAPA), a 9-item tool you can easily use in the office. We liked that this study based its claims on differences large enough to be clinically important to patients rather than just “statistically significant” differences. This study is freely available in full-text form, but it’s analytically thorny and not an easy read. We’ll break it down for you.
How’s It Stack Up?
As with humeral shaft fractures, it seems clear enough from many prior studies (including nice RCTs) that surgery and nonsurgical management for distal radius fractures differ little in terms of patient-reported outcomes for pain and function in patients over the age of 65 or so. But that generalization — and the associated AAOS clinical practice guideline on the topic — is drawn mainly from observations of people of particular chronological ages (as opposed to physiological age or measured activity levels), and it focuses on endpoints pretty far downstream from injury, typically more than a year later. The current study addresses the questions of surgeons who wonder whether surgery is justified based on early restoration of pain and function (within the first year), or whether the very active 67-year-old should be offered an operation because she doesn’t look like the “typical” patient in those earlier RCTs.
What’s Our Take?
If you take a moment to make sure that you’re offering surgery to the same patients whom these authors identified as “active,” you’re more likely to replicate their gratifying result. And it’s easy to do. The tool they used (RAPA) is freely available in several languages, can be administered in person or by phone, and takes under a minute to use. While one has to be careful being too confident when using secondary analyses of randomized trials, the effect sizes for very active patients in this study were large enough to make surgery potentially worth talking about (particularly if the patient does not have many serious medical comorbidities), and it gives surgeons a basis in good evidence to answer the question that partners (or insurers) might ask: “Why are you operating on this 70-year-old patient's wrist fracture?“ Not every patient is active enough to clear the bar set by this study, and not every active patient will want surgery (casting does pretty well for many patients), but some are and some will, and this study helps you pick ‘em.
Jayaram M, Wu H, Yoon AP, Kane RL, Wang L, Chung KC. Comparison of Distal Radius Fracture Outcomes in Older Adults Stratified by Chronologic vs Physiologic Age Managed With Casting vs Surgery. JAMA Netw Open. 2023;6:e2255786.