Introduction

Distal radius fracture (DRF) is one of the most frequently occurring upper extremity fractures we encountered in daily practice [1], particularly in patients with osteoporosis [2]. Open reduction and internal fixation with volar plating is one of the common forms of operative management for DRF with intra-articular involvement [3,4]. The British Society for Surgery of the Hand (BSSH, 2018) suggested that delay in surgery for DRF may lead to complications e.g. pain or complex regional pain syndrome (CRPS) and subsequently an inferior patient outcome [5]. There were no clear guidelines regarding the effect of timing of surgical intervention and the functional outcome. National Institute for Health and Care Excellence (NICE guideline, 2016) recommended surgical intervention should be performed within 72 hours of injury for intra-articular fracture[6].

Shawn Khan et al [7] suggested that a delay in time-to-surgery greater than two weeks for DRF may be associated with inferior patient-reported outcomes.  Yamashita et al [8] suggested that early open reduction and internal fixation for patients with extra-articular DRF within one day of injury may expect to have better short-term outcomes. However, patients with intra-articular DRF were not included in that study.

It raises concern because a considerable portion of patients with intra-articular DRF may consider to be treated conservatively despite the presence of risk factors of fracture displacement [9]. We aim to investigate the impact of timing of surgery on patients’ functional outcomes including short term and long term after surgical fixation with volar plating for intra-articular DRF. We hypothesised that earlier the surgery was performed from timing of injury results in better functional outcomes in keeping with the NICE guideline.

Methods

In this retrospective cohort study, the hospital database was reviewed for patients with DRF with operation done from 1 Mar 2019 to 31 Mar 2021. The study was approved by the Research Ethics Committee of the Hospital Authority, Hong Kong.

Our inclusion criteria were: Adults aged ≥18 years old, closed fracture with intra-articular fracture pattern, open reduction and internal fixation with volar locking plate only and no prior open reduction and internal fixation treatment of the wrist and completion of a rehabilitation programme after operation. The flow chart about patient exclusion is shown in fig 1.

Figure 1

Flowchart of patient selection

The exclusion criteria included operative management other than volar locking plate e.g. K wire fixation or external fixation, open fracture, concomitant same-side upper limb  injury (e.g. elbow fracture or dislocation, shoulder fracture or dislocation or humeral fracture) that affected the overall functional outcome, documented neurological deficit or cognitive impairment that affected rehabilitation etc.

178 patients were identified from the database. 65 patients were excluded from the study including 6 patients with bilateral or concomitant upper limb fracture, 11 patients treated with K wire or external fixator, 6 patients prescribed with brace postoperatively, 39 patients lost to follow up, 2 patients passed away and 1 patient diagnosed with cardiovascular accident within the designated period.

A total of 113 patients were identified. All patients included were active and independent in activities of daily living.  All patients were initially managed with closed reduction under local anaesthesia and plaster of paris for temporary immobilization. All patients included were treated with an open reduction via modified Henry’s approach and internal fixation with volar locking plate. All operations were performed by specialists or trainees under supervision by specialists. All patients were routinely referred for a course of physiotherapy and occupational therapy. All patients were followed up in the out-patient clinic post-operatively. All patients were followed up in the out-patient clinic at one month, three to six months, nine to twelve months postoperatively. All patients participated in the out-patient physiotherapy and occupational therapy program which emphasized on early active and passive mobilization, strengthening exercise and functional training. Patients treated with K wire fixation or external fixation were excluded in the study as they were not able to follow the same post-operative rehabilitation protocol by physiotherapist and occupational therapist.

Range of wrist motions was measured by physiotherapists using a goniometer. Grip strength of both hands were measured by occupational therapists using a dynamometer. Grip strength ratio was calculated by dividing the grip strength of the injured side by that of the uninjured side and score was expressed in percentage.

Functional outcome was assessed using quick Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) score [10] via means of interview in clinic setting or telephone interview retrospectively at a mean of 16 months (ranging from 12-18 months) from injury.

Electrical patient records and digital imaging records were reviewed for evidence of complications.

The primary outcomes include the range of motion, grip strength and Quick DASH score. Secondary outcomes include the numeric pain rating scales and complications of surgery.

We defined early fixation group as patients who were operated within three days from injury, the intermediate group as patients who were operated between four to six days from injury and the delayed fixation group as patients who were operated after seven days or more from injury.

Statistical method

Patient and injury characteristics were described using means and frequencies. Histograms were used to confirm the normality of continuous variables.

For categorical variables, Chi-squared test was used.  For continuous variables, one way analysis of variance (ANOVA) was used for normally distributed data and a post-hoc Tukey test was conducted for multiple comparison. Kruskal-Wallis test was used for non-normally distributed data and a post-hoc Dunn’s test was conducted for multiple comparison. A P-value less than 0.05 was considered statistically significant.

Results

Patient demographic was demonstrated in Table 1. Out of 113 patients enrolled in this study, 32 patients were operated within 3 days, 42 patients were operated between 4-6 days and 39 patients were operated after 7 or more days from injury. The mean days from injury to operation performed for each group were 2.47, 4.86 and 9.54 respectively. Sets of data showed no statistically significant differences in characteristics among 3 groups.

Table 1

Patient Characteristics

Among the delayed group, 16 patients (41%) were operated beyond 7 days from injury due to limited operation list, 7 patients (18%) were delay presented to our out-patient clinic, 7 patients (18%) were initially indecisive and changed their mind upon follow up,  5 patients (13%) were prioritised for pre-operative optimization and 4 patients (10%) failed initial conservative management.

Range of motion was demonstrated in Table 2 with post-hoc Dunn test illustrated in Table 3. It was statistically comparable in 1 month postoperatively between early group and intermediate group and both showed significantly better range of motion when compared with delayed group. Mean combined flexion-extension range was 94, 85 and 56 degree and mean combined forearm rotation range was 137, 132, 109 degree in early group, intermediate group and delayed group respectively (p<0.05). In 3-6 months and 9-12 months, it was statistically comparable among 3 groups in terms of mean combined flexion-extension range and mean combined forearm rotation range. Line chart for mean combined flexion-extension range and combined forearm rotation range of 3 groups was illustrated in Figure 2.

Table 2

Clinical outcomes (Range of motion)

Table 3

post-hoc Dunn’s test for multiple comparison

Figure 2

Line chart for mean combined flexion-extension range and combined forearm rotation range of 3 groups

Grip strength was demonstrated in Table 4. Among 3 groups, it was statistically insignificant in 3-6 months and 9-12 months postoperatively.

Table 4

Clinical outcomes (Grip strength)

Numeric rating pain scale (NRPS) was demonstrated in Table 5. Among 3 groups, it was statistically insignificant in 1 month, 3-6 months and 9-12 months postoperatively.

Table 5

Clinical outcomes (Numeric Rating Pain Scale)

Quick DASH scores were demonstrated in Table 6 with post-hoc Dunn’s test illustrated in Table 7. It was statistically comparable between early group and intermediate group and both groups of patients perceived less impairment than those in delayed group. The mean DASH scores were 8.2, 10.9 and 17.6 in early group, intermediate group and delayed group respectively (p<0.05). Distribution chart for Quick DASH score of 3 groups was illustrated in Figure 3.

Table 6

Functional outcome

Table 7

Post-hoc Dunn’s test for multiple comparison

Figure 3

Box plot showing Quick DASH Score in 3 groups

Fracture union was demonstrated in all study subjects. In terms of complications, no postoperative wound infection, carpal tunnel syndrome, malunion or non-union were reported.

Discussion

The British Society for Surgery of the Hand suggested that surgical intervention should be performed within 72 hours of injury for intra-articular fracture. Our study found that early fixation within seven days from injury achieved better range of motion at one month postoperatively and superior functional outcome in long term when compared with delayed fixation. However early fixation within four to six days from injury showed similar outcomes with those fixated within three days from injury. No complications in terms of wound infection, carpal tunnel syndrome or non-union were noted among three groups.

Khan et al [7] conducted a systemic review and suggested that a delay in time-to-surgery greater than two weeks for distal radius fractures may be associated with inferior patient-reported outcomes. Early surgery was associated with improved long-term DASH scores. Our study also demonstrated similar results with better functional outcomes for patients with DRF  after early surgery. However, the systemic review conducted used a two-week threshold instead of seven days in contrast to our study.

Yamashita et al [8] suggested that patients with dorsally displaced extra-articular DRF have better short term outcomes by comparing patients for surgery on the day of injury or the next day versus patients for surgery at seven days after injury or later in terms of wrist motion, GS and DASH. Our study targeted patients with intra-articular DRF and we also demonstrated better short term range of motion after early surgery within seven days from injury. However, surgery within three days from injury indeed showed no superior clinical outcomes when compared with surgery at four to six days from injury.

Sirnio et al [11] suggested that DASH score at 2 years favored early surgery over initial nonoperative treatment of displaced DRF and early surgery resulted in earlier recovery of wrist extension than achieved with primary nonoperative treatment. Delayed surgery in cases of secondary displacement after initial nonoperative treatment did not provide comparable results to early surgery in terms of DASH score. However, their control group included both patients who underwent surgery after two weeks from injury and patients who were treated with cast immobilization for a total of six weeks which may lead to more heterogeneous results instead of only including patients who received surgery in the study.

Bae et al [12] and Macfarlane et al  [13] suggested functional score was comparable between early surgery within 14 days and delayed surgery. However, Bae mainly focused on patients with metaphyseally malaligned DRF including AO Class A3 and C2 while DRF with articular step-off were excluded from their study. In Marcfarlane’s study, Dorsal plaster of Paris (POP) splint was applied for two weeks and a removable wrist splint was applied for another four weeks for all patients.  Ashdown et al [14] also showed an increase in postoperative finger and thumb stiffness in patients with delayed surgery more than two weeks. Patients in his study were splinted for a mean 1.5 weeks after surgery. On the other hand, all patients in our cohort study underwent immediate active and passive mobilization exercise after surgery without splintage. It demonstrated that early post-operative mobilization is one of the key factors for better functional outcome while splintage may hinder rehabilitation.

Early operation also prevents prolonged pre-operative immobilization, persistent swelling and pain. It promotes early functional rehabilitation and allows early start of physiotherapy and occupational therapy. Jayakumar [15] suggested greater pain interference, greater fear of movement as strong predictors of limitations to rehabilitation after DRF. It demonstrated that a patient's psychological factor also played an important role upon optimizing recovery. Hooper [16] demonstrated surgery performed less than seven days after DRF led to better surgeon-perceived reduction quality and less procedural difficulty. For surgery performed more than seven days after injury, surgeons judged the reduction quality less favorable may affect the postoperative rehabilitation such as prolonged splintage and hindered early mobilization.

Range of motion and grip strength were statistically comparable among 3 groups at 3 to 6 months and 9 to 12 months while DASH scores in early group and intermediate group were statistically better than those in the delayed group at 1.5 years. Reasonably, better range of motion and grip strength should result in less disability. Karnezis et al [17] found no significant correlation between range of motion in terms of pronation-supination arc and extension-flexion arc and the functional score. Palmer et al [18]  suggested that operative procedures that limit wrist motion are not necessarily functionally detrimental. Beumer et al [19] suggested that grip strength ratio correlates with the DASH score in different hand and wrist conditions. We postulate that there may be some limitations in our study that may contribute to the difference. Josária et al [20] proposed that the variety of available hand-held dynamometers and their different handle shapes may influence the measurements of grip strength and Su et al [21] suggested grip strength varies in different positions of elbow and shoulder. We try to limit the difference by calculating the grip strength ratio instead of grip strength but it may still not be able to eliminate the bias. It is suggested that grip strength should be measured by the same dynamometer and same elbow and shoulder position in serial measurements of individuals.

Early fixation of DRF may sometimes be difficult to achieve from various perspectives. We observed that among our delayed group of patients, a number of patients were delayed presenting to our out-patient clinic or initially indecisive. It suggests that patients’ willingness and active participation in decision making plays an important role for functional outcome.

There are some limitations in this study. There is a possibility of self-selection bias among the patients who were compliant to follow up and rehabilitation for better functional outcome. The follow-up time post-operatively was not standardized in this retrospective cohort study. Operations were performed by surgeons of various levels of experience, including trainees and specialists. Upon documentation of grip strength by physiotherapists and occupational therapists, hand dominance was not taken into account. Further prospective studies such as randomized controlled trials with larger sample size may be suggested.

Conclusion

For patients with intra-articular distal radius fracture undergoing operation with volar plating, early operation within seven days from injury results in superior functional outcomes when compared with delayed operation. Operation within three days from injury showed no added benefit when compared with operation in four to six days from injury.