SCIENTIFIC ARTICLE

Comparative Analysis of Intramedullary Nail Fixation

Versus Casting for Treatment of Distal Radius Fractures
Virak Tan, MD, Walter Bratchenko, MS, Ali Nourbakhsh, MD, John Capo, MD

Purpose Intramedullary fixation is one treatment option for distal radius fractures. Our purpose was to
compare the outcomes of intramedullary nailing to those of casting for these injuries.
Methods From 2006 to 2009, we reviewed 63 adult patients with isolated distal radius
fractures. Thirty-one patients had surgical fixation with an intramedullary device (IMN
group) within 4 weeks of the injury, and 32 (cast group) had casting as definitive treatment
of the fracture. Clinical outcomes (grip strength; Disabilities of the Arm, Shoulder, and Hand
scores; active wrist range of motion; and complications) and radiographic indices (radial
inclination, radial height, ulnar variance, and tilt) of both groups were analyzed for the 1-,
2-, 4-, 6-, and 12-month follow-up periods.
Results The flexion– extension arc was significantly higher in the IMN group than in the cast
group at 2-, 6-, and 12-month follow-up. The IMN group exhibited significantly greater grip
strength and lower DASH scores throughout the follow-up period. At final follow-up, all
radiographic indices were significantly better in the IMN group than in the cast group. There
was no significant difference between the initial reduction to final position in the IMN group,
but the cast group showed an increase in ulnar variance and a significant change in
dorsal–volar tilt. In addition, the cast group experienced more clinical complications in the
delayed period compared to the IMN group.
Conclusions Intramedullary nail fixation, as compared to casting, results in less functional dis-
ability, not only in the early postoperative period but also up to a year after treatment. On the basis
of our data, intramedullary fixation should be considered for patients with unstable extra-articular
or simple intra-articular distal radius fractures. (J Hand Surg 2012;37A:460–468. Copyright
© 2012 by the American Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Prognostic II.
Key words Cast, distal radius fracture, early motion, intramedullary nail, wrist.

casting remains the stan- fixation using locked plating systems has been the main-

C
LOSED REDUCTION AND
dard of care for most distal radius fractures stay of surgical treatment of displaced intra-articular or
(DRFs) with minimal comminution or articular unstable extra-articular fractures in adults.2 More recently,
1
stepoff. Over the last decade, open reduction and internal intramedullary fixation has also emerged as a viable treat-
ment.3–5
From the Department of Orthopedics, University of Medicine and Dentistry of New Jersey, New Jersey
Even though DRFs are among the most common
Medical School, Newark, NJ. orthopedic injuries, the optimal treatment remains a
Received for publication April 20, 2011; accepted in revised form October 20, 2011. topic of debate. It is generally agreed that stable frac-
V.T. and J.C. are consultants for and receive royalties from Wright Medical Technology. tures can be managed nonsurgically with satisfactory
Correspondingauthor: VirakTan,MD,UniversityofMedicineandDentistryofNewJersey,New
outcomes. Some have suggested that unstable DRFs in
Jersey Medical School, Department of Orthopedics, ACC D1626, 140 Bergen St., Newark, NJ 07103; the elderly can be treated with casting alone because
e-mail: [email protected]. alignment is not associated with functional outcomes,
0363-5023/12/37A03-0009$36.00/0 as it is in younger patients.6,7 Others recommend open
doi:10.1016/j.jhsa.2011.10.041
reduction and internal fixation.8 –11 The controversy

460 䉬 ©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved.

 IMN VERSUS CASTING FOR DISTAL RADIUS FRACTURES 461

FIGURE 1: A Lateral and B posteroanterior injury radiographs of a 60-year-old woman with an AO/ASIF type C2 fracture.

might, in part, lie in the paucity of studies directly cluded multi-extremity injuries, complex intra-articular
comparing surgical to nonsurgical treatment of DRFs. fracture (AO/ASIF C3), and age younger than 18 years.
To date, only a few studies have examined surgical Patients who had other forms of treatment for DRFs or
fixation versus closed treatment of DRFs12–14; there- who had less than 1-year follow-up were also excluded.
fore, the question, “Does surgical treatment have better In total, 63 patients were included in this study, with
results than casting?” remains. an average follow-up time of 13 months. All fractures
The purpose of the current study was to compare the were classified according to the AO/ASIF classification
outcomes of intramedullary nailing (IMN) to casting for system15 (Table 1). At initial presentation, all patients had
DRFs. We sought to answer the following questions: a reduction maneuver of the fracture under a hematoma
(1) Can open reduction with intramedullary fixation block and were placed into a sugar-tong splint. Radio-
give better results than casting? (2) Are there radio- graphs were used to assess the fracture alignment after
graphic differences between these groups? (3) Are there manipulation. For patients in whom the reduction could
noteworthy complications from the treatments? not be achieved after 2 attempts (dorsal tilt ⬎ 20°, short-
ening ⱖ 3 mm, or articular stepoff ⱖ 2 mm), surgical
MATERIALS AND METHODS treatment was advised.16 In the post-reduction period, pa-
From 2006 to 2009, we conducted an institutional re- tients were followed up weekly for 4 weeks with serial
view board–approved, retrospective study on prospec- radiographs. Those who lost reduction (defined earlier)
tively collected data in patients with DRFs. The study during this timeframe were advised to have surgery.
consisted of 2 groups: the IMN group—patients who
had surgical fixation with an intramedullary device (Mi- Surgical treatment protocol—IMN group
cronail, Wright Medical Technology, Inc, Arlington, During the study period, the senior author (V.T.) operated
TN) within 4 weeks of the injury (Figs. 1, 2), and the on 84 isolated DRFs. Of these 84 DRFs, 52 had intramed-
cast group—patients who had casting as definitive treat- ullary fixation, 23 had locked volar plating, 5 had percu-
ment of the fracture. Patients who initially were treated by taneous pinning, 3 had locked volar plating and external
immobilization but went on to surgery due to re- fixation, and 1 had screw fixation alone. Initial assessment
displacement of the fracture were excluded from the cast of whether the fracture pattern was amenable to IMN was
group, but they were included in the IMN group if they done before surgery, based on radiographs. For all extra-
had intramedullary fixation. Other exclusion criteria in- articular and simple intra-articular fractures, intramedul-

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462 IMN VERSUS CASTING FOR DISTAL RADIUS FRACTURES

FIGURE 2: A Lateral and B posteroanterior postoperative radiographs of the patient in Figure 1.

lary fixation was the device of choice. For fractures with Nonsurgical treatment protocol— cast group
small and comminuted articular fragments, open reduction The demographics of the 32 patients in the cast group
and locked volar plating was typically chosen. The final and their injury patterns are reported in Table 1. Active
decision for the mode of fixation was made during sur- and passive finger motion was encouraged immedi-
gery. If the fracture could be reduced by closed or percu- ately. These patients were seen weekly for serial radio-
taneous means, IMN was performed. graphs. No repeat manipulation was done.
Of the 52 patients who had IMN, 31 patients (2 men, There were 4 patients (in addition to the 32 in the
29 women) with a mean age of 65 years (range, 27– 89; cast group) who had re-displacement of the fracture.
SD, 15) met criteria for inclusion in the study. The These patients were converted to IMN and were in-
AO/ASIF fracture patterns are reported in Table 1. Four cluded in the IMN group for analysis.
of the injuries were open. At the 2-week mark, the splint was changed to a
All surgical procedures were performed under gen- Muenster cast. Then a short-arm cast was placed at 4
eral or regional anesthesia, using the technique as pre- weeks. The duration of casting was based on clinical
viously described.3 No bone grafting was used. In ad- and radiographic evidence of healing of the fracture.
dition to the IMN, 1 patient with an open distal Immobilization averaged 35 days (range, 21–51 d; SD,
radioulnar joint (DRUJ) dislocation had capsular repair. 8.8). Formal therapy was individualized. Average fol-
Five of the 13 fractures with associated distal ulnar low-up time was 14 months (range, 11–23 mo).
(styloid, 4; neck, 1) fractures also had ulnar fixation.
After surgery, the wrist was not immobilized unless
the distal ulna fracture also had fixation or the DRUJ Functional assessment
was unstable, in which case these patients were immo- A physician assistant (W.B.) who was not involved in
bilized with sugar-tong splints. The average time of the initial assessment or treatment obtained the func-
immobilization was 5 days (range, 0 –31; SD, 9.2) for tional outcome measures. Assessment included active
the entire group. For the 6 patients who had postoper- wrist flexion– extension, radial– ulnar deviation, and
ative immobilization, the average was 23 days. Patients forearm rotation using a goniometer. Grip strength was
who were not immobilized were allowed immediate measured on the second position of a hand dynamom-
forearm, wrist, and finger motion. Formal therapy was eter (Jamar, Irvington, NY) with the patient seated,
individualized. Average follow-up time was 13 months shoulder adducted, elbow flexed 90°, and forearm in
(range, 12–17 mo). neutral position. The average of 3 measurements was

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 IMN VERSUS CASTING FOR DISTAL RADIUS FRACTURES 463

TABLE 1. Demographics and Fracture Patterns TABLE 2. Active Arcs of Motion

P IMN (°) Cast (°) P Value
IMN Cast Value
2 mo
Number of patients 31 32 F-E 95 ⫾ 24 (n ⫽ 28) 71 ⫾ 27 (n ⫽ 26) ⬍.001
Age 65 ⫾ 15 y 63 ⫾ 18 y .618 R-U 43 ⫾ 14 (n ⫽ 30) 30 ⫾ 11 (n ⫽ 25) ⬍.001
Gender S-P 155 ⫾ 21 (n ⫽ 30) 139 ⫾ 37 (n ⫽ 26) .05
M 2 (6%) 3 (9%) 4 mo
F 29 (94%) 29 (91%) .886 F-E 107 ⫾ 23 (n ⫽ 29) 94 ⫾ 30 (n ⫽ 23) .07
Hand dominance R-U 45 ⫾ 12 (n ⫽ 29) 42 ⫾ 13 (n ⫽ 23) .46
R 29 (94%) 31 (97%) S-P 155 ⫾ 25 (n ⫽ 29) 160 ⫾ 20 (n ⫽ 23) .42
L 2 (6%) 1 (3%) .787 6 mo
Dominant extremity 20 (65%) 22 (69%) F-E 130 ⫾ 21 (n ⫽ 29) 98 ⫾ 21 (n ⫽ 26) ⬍.001
fractured
R-U 48 ⫾ 11 (n ⫽ 29) 42 ⫾ 11 (n ⫽ 26) .05
AO/ASIF classification
S-P 163 ⫾ 16 (n ⫽ 29) 162 ⫾ 15 (n ⫽ 26) .89
A2 8 (26%) 17 (53%)
12 mo
A3 10 (32%) 2 (6%)
F-E 125 ⫾ 19 (n ⫽ 31) 102 ⫾ 25 (n ⫽ 29) ⬍.001
B1 0 1 (3%)
R-U 51 ⫾ 9 (n ⫽ 31) 45 ⫾ 13 (n ⫽ 29) .06
B3 1 (3%) 0 .015
S-P 165 ⫾ 16 (n ⫽ 31) 166 ⫾ 17 (n ⫽ 29) .94
C1 7 (23%) 10 (31%)
C2 5 (16%) 2 (6%) F-E, flexion-extension; R-U, radial-ulnar deviation; S-P,
supination-pronation.
Associated distal ulnar
injury
Fracture 13 (42%) 3 (9%) .002
period and at the 1-year mark. Radiographic measure-
DRUJ dislocation 1 (3%) 0
ments from initial and 1-, 2-, 4-, 6-, and 12-month
Mechanism of injury
follow-ups were recorded and analyzed. The following
Low energy* 25 (81%) 26 (81%)
parameters were measured: tilt, radial inclination, radial
High energy† 6 (9%) 5 (16%)
height, and ulnar variance. The tilt was measured on the
Assault 0 1 (3%) lateral view and expressed as the number of degrees
*Low-energy injury—simple fall. from the neutral position18 (positive indicates dorsal tilt
†High-energy injury—fall from height, motor vehicle accident, or and negative indicates volar tilt). Posttraumatic arthritis
work- or sport-related accident.
at follow-up was classified using the Knirk and Jupiter
classification system.19

recorded for grip. The Disabilities of the Arm, Shoul- Complications

der, and Hand (DASH) scores were recorded. Complications were categorized into minor (requiring
Data were obtained at 1 month (3–5 wk), 2 months no surgery) or major (requiring surgery), and early
(7–10 wk), 4 months (14–18 wk), 6 months (22–26 wk), (occurring within 2 months) or delayed (occurring after
and 1 year (11 mo or greater). The range of motion and 2 months). In the early timeframe, finger stiffness was
grip strength data at the 1-month follow-up were not in- defined as inability to touch the palm with the finger-
cluded in the analysis because patients in the cast group tips. In the delayed period, stiffness was defined as
were still in or just recently out of immobilization. At the inability to touch the distal palmar crease.
2-month follow-up, grip and range of motion were re-
corded only if patients had been out of immobilization for Statistical methods
a minimum of 2 weeks. Grip strength was determined as See the Appendix, which can be viewed on the Jour-
a percentage of the uninjured side, with a 10% adjustment nal’s Web site at www.jhandsurg.org.
for hand dominance.17
RESULTS
Radiographic assessment Clinical results
Standard posteroanterior and lateral radiographs were The mean active arcs of motion are given in Table 2.
obtained as clinically indicated during the treatment The flexion– extension (F-E) arc was significantly

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464 IMN VERSUS CASTING FOR DISTAL RADIUS FRACTURES

100
90 p=0.036
p=0.008
80
p=0.134
70

% Grip Strength
p=0.024
60
50 IMN
cast
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12
Follow-up (months)

FIGURE 3: Graph showing the percentage mean grip strength of the injured hand (compared to the uninjured side) in the IMN and
cast groups.

60
p=0.007

50
DASH Score

40
p=0.011

p<0.001 IMN
30 p<0.001
p<0.001 cast

20

10

0
1 2 3 4 5 6 7 8 9 10 11 12
Follow-up (months)

FIGURE 4: Graph of the mean DASH scores in the IMN and cast groups.

higher in the IMN group than in the cast group at the 2-, was at least 14 points. For the AO/ASIF type A frac-
6-, and 12-month follow-ups. The radial– ulnar (R-U) tures (Table 3), there were significant differences in F-E
deviation was better in the IMN group at 2 and 6 and R-U at 2 months, in DASH at 4 months, in F-E and
months; however, there was no difference at the final R-U at 6 months, and in F-E and percent grip at 12
follow-up. Except at the 2-month follow-up, there was months.
no statistically significant difference for supination– For the AO/ASIF type C fractures (Table 4), there
pronation (S-P) arc between the groups. were significant differences in R-U at 2 months; in
The mean grip strength is shown in Figure 3. The IMN DASH at 4 months; in F-E, percent grip, and DASH at
group exhibited significantly greater grip strength at 2 6 months; and in F-E and DASH at 12 months. Anal-
months, 6 months, and 12 months, but not at 4 months. ysis of AO/ASIF type B fractures was not performed
The mean DASH scores are presented in Figure 4. because there were only 2 patients in this category.
Patients in the IMN group reported significantly less In general, duration of immobilization negatively af-
disability for all time periods. The difference observed fected motion and grip. In addition, longer immobilization

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 IMN VERSUS CASTING FOR DISTAL RADIUS FRACTURES 465

TABLE 3. Clinical Outcome Measures for AO/ TABLE 4. Clinical Outcome Measures for AO/
ASIF Type A Fractures ASIF Type C Fractures
IMN Cast P Value IMN Cast P Value

2 mo 2 mo
F-E (°) 96 ⫾ 18 73 ⫾ 32 .028 F-E (°) 91 ⫾ 25 69 ⫾ 20 ns
R-U (°) 41 ⫾ 12 29 ⫾ 13 .016 R-U (°) 52 ⫾ 6 29 ⫾ 7 ⬍.001
S-P (°) 151 ⫾ 25 140 ⫾ 36 ns S-P (°) 159 ⫾ 13 141 ⫾ 37 ns
% Grip 62 ⫾ 19 47 ⫾ 27 ns % Grip 54 ⫾ 21 38 ⫾ 22 ns
DASH 19 ⫾ 13 32 ⫾ 24 ns DASH 26 ⫾ 20 42 ⫾ 24 ns
4 mo 4 mo
F-E (°) 113 ⫾ 20 99 ⫾ 32 ns F-E (°) 103 ⫾ 25 90 ⫾ 28 ns
R-U (°) 43 ⫾ 11 42 ⫾ 13 ns R-U (°) 51 ⫾ 12 41 ⫾ 14 ns
S-P (°) 153 ⫾ 23 160 ⫾ 16 ns S-P (°) 155 ⫾ 32 148 ⫾ 20 ns
% Grip 77 ⫾ 17 70 ⫾ 17 ns % Grip 68 ⫾ 25 66 ⫾ 30 ns
DASH 13 ⫾ 13 25 ⫾ 15 .046 DASH 11 ⫾ 13 40 ⫾ 22 .003
6 mo 6 mo
F-E (°) 124 ⫾ 18 106 ⫾ 17 .014 F-E (°) 121 ⫾ 19 81 ⫾ 21 ⬍.001
R-U (°) 50 ⫾ 8 41 ⫾ 11 .027 R-U (°) 50 ⫾ 11 41 ⫾ 10 ns
S-P (°) 164 ⫾ 12 159 ⫾ 13 ns S-P (°) 160 ⫾ 21 159 ⫾ 17 ns
% Grip 90 ⫾ 21 82 ⫾ 16 ns % Grip 84 ⫾ 17 61 ⫾ 29 .049
DASH 10 ⫾ 13 22 ⫾ 21 ns DASH 8 ⫾ 11 36 ⫾ 24 .003
12 mo 12 mo
F-E (°) 128 ⫾ 20 106 ⫾ 25 .011 F-E (°) 121 ⫾ 15 94 ⫾ 26 .010
R-U (°) 50 ⫾ 7 46 ⫾ 13 ns R-U (°) 51 ⫾ 9 43 ⫾ 12 ns
S-P (°) 161 ⫾ 21 168 ⫾ 13 ns S-P (°) 170 ⫾ 8 161 ⫾ 22 ns
% Grip 94 ⫾ 16 82 ⫾ 16 .036 % Grip 83 ⫾ 19 73 ⫾ 33 ns
DASH 8 ⫾ 10 21 ⫾ 23 ns DASH 5⫾8 33 ⫾ 25 .024

F-E, flexion-extension arc; R-U, radial-ulnar deviation arc; S-P, su- F-E, flexion-extension arc; R-U, radial-ulnar deviation arc; S-P, su-
pination-pronation arc; ns, not significant. pination-pronation arc; ns, not significant.

led to higher DASH scores, indicating more disability. Fracture union was achieved in all patients. At final
These relationships were significant at 12 months for all follow-up, 1 patient in the IMN group and 7 patients in
clinical parameters except for S-P (Table 5). the cast group showed radiographic evidence of radio-
carpal arthritis (P ⫽ .053).
Radiographic results
Overall, there was no difference in initial post-reduction Complications
radiographs between the IMN and cast groups, except The IMN group: In the early period, 7 patients had minor
for radial height (11.8 ⫾ 1.5 mm vs 10.5 ⫾ 2.4 mm, complications, and none had a major complication. The 3
respectively; Table 6). At final follow-up, tilt, radial patients with radial sensory nerve neuritis had resolution of
inclination, radial height, and ulnar variance were sig- symptoms by the 4-month follow-up. The patient who
nificantly better in the IMN group than in the cast group developed complex regional pain syndrome required 6
(Table 6). months of hand therapy before the symptoms abated. In
When comparing the initial post-reduction position the delayed period (ie, after 2 mo), there were no compli-
to final position within each treatment group, no signif- cations in the IMN group.
icant differences were seen for the IMN group, but There was no tendon or soft tissue irritation, no
significant differences in ulnar variance and tilt existed screw penetration into the joint, or wound healing prob-
for the cast group, showing statistically significant lem in either time period. No hardware removal was
worsening ulnar variance and loss of volar tilt (Table 7). required in the follow-up period (Table 8).

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TABLE 5. Spearman Rank Order Correlation TABLE 6. Radiographic Indices Between the
Coefficients Between Duration of Immobilization Groups at Initial Reduction and Final Follow-Up
and Clinical Outcome Parameters
Indices IMN Cast P Value
IMN Cast IMN Plus Cast*
Initial reduction
2 mo UV (mm) ⫺0.3 ⫾ 1.3 0.0 ⫾ 1.7 .528
F-E ⫺0.246 ⫺0.322 ⫺0.426 (.005) RI (°) 22.9 ⫾ 3.1 22.1 ⫾ 4.6 .414
R-U ⫺0.058 ⫺0.207 ⫺0.468 (.001) RH (mm) 11.8 ⫾ 1.5 10.5 ⫾ 2.4 .019
S-P 0.087 ⫺0.412 (.036) ⫺0.221 Tilt (°) ⫺6.8 ⫾ 5.1 ⫺4.0 ⫾ 7.0 .083
% Grip ⫺0.296 ⫺0.496 (.010) ⫺0.288 Final follow-up
DASH ⫺0.009 0.236 ⫺0.171 UV (mm) 0.3 ⫾ 1.5 1.7 ⫾ 2.2 .004
4 mo RI (°) 23.3 ⫾ 3.1 19.8 ⫾ 4.9 .002
F-E ⫺0.283 ⫺0.243 ⫺0.312 (.035) RH (mm) 11.1 ⫾ 1.5 10.0 ⫾ 2.3 .028
R-U ⫺0.275 ⫺0.098 ⫺0.183 Tilt (°) ⫺8.9 ⫾ 5.2 2.2 ⫾ 11.8 ⬍.001
S-P ⫺0.416 (.031) 0.074 ⫺0.181
UV, ulnar variance; RI, radial inclination; RH, radial height; Tilt,
% Grip ⫺0.379 ⫺0.080 ⫺0.241 lateral alignment.
DASH 0.035 ⫺0.057 0.376 (.013)
6 mo
F-E ⫺0.485 (.008) ⫺0.033 ⫺0.530 (⬍.001)
R-U ⫺0.215 0.003 ⫺0.370 (.008) TABLE 7. Radiographic Indices at Initial
Reduction Compared to Final Follow-Up for the
S-P ⫺0.202 ⫺0.083 ⫺0.202
Groups
% Grip ⫺0.132 ⫺0.210 ⫺0.084
DASH 0.042 0.174 0.365 (.010) Indices Initial Reduction Final Follow-Up P Value
12 mo IMN
F-E ⫺0.482 (.011) ⫺0.067 ⫺0.489 (⬍.001) UV (mm) ⫺0.3 ⫾ 1.5 0.3 ⫾ 1.5 .153
R-U ⫺0.235 ⫺0.208 ⫺0.354 (.007) RI (°) 22.8 ⫾ 3.1 23.3 ⫾ 3.1 .525
S-P ⫺0.358 ⫺0.094 ⫺0.040 RH (mm) 11.8 ⫾ 1.6 11.1 ⫾ 1.1 .106
% Grip ⫺0.084 ⫺0.328 ⫺0.276 (.034) Tilt (°) ⫺7.5 ⫾ 5.0 ⫺8.9 ⫾ 5.2 .281
DASH ⫺0.174 0.111 0.325 (.013) Cast

F-E, flexion-extension arc; R-U, radial-ulnar deviation arc; S-P, su-

UV (mm) 0.0 ⫾ 1.7 1.7 ⫾ 2.2 .010
pination-pronation arc. RI (°) 22.1 ⫾ 4.6 19.8 ⫾ 4.9 .073
*Significant P values are given in parentheses.
RH (mm) 10.5 ⫾ 2.4 10.0 ⫾ 2.3 .387
Tilt (°) ⫺4.0 ⫾ 7.0 2.2 ⫾ 11.8 .017

UV, ulnar variance; RI, radial inclination; RH, radial height; Tilt,
The cast group: For this group, 10 patients developed lateral alignment.
minor complications, and no patient had a major com-
plication in the early timeframe. In the delayed period,
5 patients had minor complications, and another 5 had
major complications (Table 8). However, we found that, in the early postoperative
period, patients who had been managed with IMN
DISCUSSION generally had better active wrist flexion– extension arc,
Initial results of the Micronail fixation have been pre- grip strength, and lower DASH scores than those who
viously published,3–5 but those studies contained rela- had been treated with casting. These differences were
tively few patients, short follow-up periods, and/or no also present for AO/ASIF types A and C fractures and
comparison group. The present study examined the were maintained even at the final follow-up, which is in
differences between DRFs managed with closed treat- contrast to other studies.8,12,21
ment and open reduction with intramedullary fixation The reasons for better outcomes in our surgery group
with follow-up of at least 1 year. Our null hypothesis might include less pain, early wrist motion, and confi-
was that there would be no significant differences in dence in the injured limb, which allowed patients to
any outcome between the 2 groups at any point in time. rapidly incorporate the limb into the activities of daily

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 IMN VERSUS CASTING FOR DISTAL RADIUS FRACTURES 467

TABLE 8. Complications
Complications IMN (n) Cast (n) P Value

Early
Minor Transient radial sensory neuritis (3) CTS (2) .572
Trigger finger (1) CTS and finger stiffness (2)
Finger stiffness (1) Finger stiffness (6)
Ulnar fixation hardware irritation (1)
Complex regional pain syndrome (1)
Major None (0) None (0)
Delayed
Minor None (0) de Quervain and CTS (2) ⬍.001
CTS (1)
Finger stiffness (2)
Major None (0) Malunion repair (2)
Ulnar shortening (2)
de Quervain release (1)

CTS, carpal tunnel syndrome.

living. We identified that duration of immobilization versus casting. At final follow-up, they found no sig-
had negative correlations with active range of motion nificant difference in mean ranges of motion, grip
and grip strength and correlated with more disability (ie, strength, DASH score, Patient-Rated Wrist Evaluation
higher DASH scores). Our supposition on the benefits score, and Green and O’Brien score. The discrepancies
of early wrist motion seems to contradict the findings of between our results and theirs might be attributed to the
Lozano-Calderon et al,22 who suggested that 6 weeks of differences in the methods of internal fixation, the mean
postoperative wrist immobilization does not compro- final follow-up periods, and the patients’ ages.
mise wrist function and DASH scores. The current The only other recent study comparing surgical to
study and the Lozano-Calderon et al study differ in conservative treatment for DRFs was a Cochrane re-
several ways. First, Lozano-Calderon et al studied pa- view by Handoll et al.12 They examined external fixa-
tients who had volar plate fixation with randomization tion versus cast immobilization and concluded that
between late and early wrist motion. They did not report there was some evidence to support external fixation
on immobilization in the setting of closed treatment of because it prevented late collapse and malunion. How-
DRF with casting, as we did. Second, the authors made ever, there was insufficient evidence to confirm better
no attempt to confirm or verify that their patients ad- functional outcome in the surgically treated patients.
hered to the recommended motion protocols. Therefore, Similar to Handoll et al12 and others14,21 who con-
patients in the late motion group could have removed cluded that surgery resulted in better radiographic pa-
their thermoplastic splints and started earlier motion rameters at healing, we also found this to be true for
than advised and vice versa, thereby narrowing any DRFs treated with IMN. However, unlike those of
difference that might have otherwise existed. Our Handoll et al,12 our surgically treated patients had better
closed treatment patients were maintained in a cast for clinical functional outcomes than the patients who were
duration of treatment, which guaranteed 100% compli- casted.
ance with immobilization. By the same token, our IMN We found no difference in the rates of complications
group patients (except for the ones with distal ulna between the surgically and nonsurgically treated pa-
fixation) were mobilized immediately without any tients in the early timeframe. All delayed complications
splinting. Third, all patients in the Lozano-Calderon et occurred in the cast group, with no delayed complica-
al study were immobilized in a volar plaster splint for 2 tions occurring in the IMN group. In the cast group, 5
weeks after the surgery, again narrowing any difference patients had minor complications, and another 5 had
that might otherwise exist between the late and early major complications requiring surgery on the injured
motion groups. wrists. The rate of secondary procedures in the cast
Arora et al14 performed a retrospective study in an group was high when compared to that of Arora et al,14
elderly patient population treated with volar plating who reported none, but it is in line with that of Handoll

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et al,12 who reported a 15% (51/338) rate of secondary 4. Ilyas AM, Thoder JJ. Intramedullary fixation of displaced distal
radius fractures: a preliminary report. J Hand Surg 2008;33A:1706 –
treatment as a result of re-displacement. 1715.
Ilyas and Thoder4 reported on 10 patients with AO/ 5. Brooks KR, Capo JT, Warburton M, Tan V. Internal fixation of distal
ASIF types A and C DRFs who had Micronail fixation. radius fractures with novel intramedullary implants. Clin Orthop
The average age of the group was 55 years, and average Relat Res 2006;445:42–50.
6. Beumer A, McQueen MM. Fractures of the distal radius in low-
follow-up was 21 months. Overall, our results are sim- demand elderly patients: closed reduction of no value in 53 of 60
ilar to theirs in range of motion, grip strength, and wrists. Acta Orthop Scand 2003;74:98 –100.
DASH score. However, we did not observe any note- 7. Young BT, Rayan GM. Outcome following nonoperative treatment
of displaced distal radius fractures in low-demand patients older than
worthy change in alignment of the distal radius from
60 years. J Hand Surg 2000;25A:19 –28.
immediately after surgery to final follow-up. In addi- 8. Arora R, Lutz M, Fritz D, Zimmermann R, Oberladstatter J, Gabl M.
tion, we did not note any screw penetration into the Palmar locking plate for treatment of unstable dorsal dislocated distal
DRUJ. Ilyas and Thoder4 seemingly attributed DRUJ radius fractures. Arch Orthop Trauma Surg 2005;125:399 – 404.
9. Beharrie AW, Beredjiklian PK, Bozentka DJ. Functional outcomes
symptoms in 3 of their patients to “apparent penetration of after open reduction and internal fixation for treatment of displaced
the subchondral screws into the distal radioulnar joint,” but distal radius fractures in patients over 60 years of age. J Orthop
they did not confirm this by computed tomography scan or Trauma 2004;18:680 – 686.
10. Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unsta-
perform surgery to remove the offending screws.
ble distal radius fractures in the elderly patient. J Hand Surg 2004;
There are several limitations of the present study. 29A:96 –102.
First, it is a retrospective review with inherent limita- 11. Ring D, Jupiter JB. Treatment of osteoporotic is distal radius frac-
tions. It might also be argued that the cast group was not tures. Osteoporosis Int 2005;16 Suppl 2:S80 – 84.
12. Handoll HH, Huntley JS, Madhok R. External fixation versus con-
comparable to the IMN group because fractures in the servative treatment for distal radial fractures in adults. Cochrane
former group are, by definition, more inherently stable. Database Syst Rev 2007:CD006194.
Patients in the cast group, in fact, were younger, had 13. Rozental TD, Blazar PE. Functional outcome and complications
less severe fracture patterns (more A2 and C1), and had after volar plating for dorsally displaced, unstable fractures of the
distal radius. J Hand Surg 2006;31A:359 –365.
fewer associated distal ulnar injuries. Despite the dif- 14. Arora R, Gabl M, Gschwentner M, Deml C, Krappinger D, Lutz M.
ferences between the groups, we felt that the cast group A comparative study of clinical and radiologic outcomes of unstable
served a useful purpose for comparison because (1) Colles type distal radius fractures in patients older than 70 years:
nonoperative treatment versus volar locking plating. J Orthop
casting is the most common form of treatment for Trauma 2009;23:237–242.
DRFs, especially in the elderly,23 and (2) we wanted to 15. Müller ME. Appendix A, The comprehensive classification of frac-
compare the treatment to the best-case scenario. An- tures of long bones. In: Müller ME, Allgöwer M, Schneider R,
other limitation is that the outcome measures were Willenegger H, eds. Manual of internal fixation. 3rd ed. New York:
Springer-Verlag, 1991:134 –135.
obtained by an orthopedic physician assistant who is 16. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional
employed by the senior surgeon (V.T.), which could outcome of displaced intra-articular distal radius fractures. J Hand
have led to bias. Surg 1994;19A:325–340.
17. Petersen P, Petrick M, Connor H, Conklin D. Grip strength and hand
Despite these shortcomings, the present study sug- dominance: challenging the 10% rule. Am J Occup Ther 1989;43:
gests that intramedullary nail fixation, as compared to 444 – 447.
casting, results in less functional disability, not only in 18. van der Linden W, Ericson R. Colles’ fracture. How should its
the early postoperative period but also up to a year after displacement be measured and how should it be immobilized?
J Bone Joint Surg 1981;63A:1285–1288.
treatment. On the basis of our data, we conclude that 19. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the
intramedullary fixation should be considered over cast- radius in young adults. J Bone Joint Surg 1986;68A:647– 659.
ing for patients with extra-articular or simple intra- 20. Gummesson C, Atroshi I, Ekdahl C. The disabilities of the arm,
shoulder and hand (DASH) outcome questionnaire: longitudinal
articular DRFs. construct validity and measuring self-rated health change after sur-
gery. BMC Musculoskelet Disord 2003;4:11.
REFERENCES 21. Figl M, Weninger P, Jurkowitsch J, Hofbauer M, Schauer J, Leix-
1. Simic PM, Weiland AJ. Fractures of the distal aspect of the radius: nering M. Unstable distal radius fractures in the elderly patient—
changes in treatment over the past two decades. Instr Course Lect volar fixed-angle plate osteosynthesis prevents secondary loss of
2003;52:185–195. reduction. J Trauma 2010;68:992–998.
2. Arora R, Lutz M, Hennerbichler A, Krappinger D, Espen D, Gabl M. 22. Lozano-Calderon SA, Souer S, Mudgal C, Jupiter JB, Ring D. Wrist
Complications following internal fixation of unstable distal radius immobilization following volar plate fixation of fractures of the
fracture with a palmar locking-plate. J Orthop Trauma 2007;21:316 – distal part of the radius. J Bone Joint Surg 2008;90A:1297–1304.
322. 23. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States
3. Tan V, Capo J, Warburton M. Distal radius fracture fixation with an in the treatment of distal radial fractures in the elderly. J Bone Joint
intramedullary nail. Tech Hand Up Extrem Surg 2005;9:195–201. Surg 2009;91A:1868 –1873.

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APPENDIX Chi-square or Fisher exact tests were used to

compare the nonparametric measures between the
This study was designed to determine a 10-point groups. The DASH scores, grip strengths, arcs of
mean difference in the DASH scores between the 2 motion, and radiographic assessments were analyzed
groups, with a standard deviation of 10 points (for using analysis of variance at different intervals be-
an effect size of 1.0).20 A power analysis indicated tween the 2 groups and between baseline and 12 months
that a sample size of 23 patients in each group within each group. Correlations between time of
would provide 90% power to detect this effect size immobilization and the clinical outcome parameters
between the groups (␣ ⫽ 0.05, ␤ ⫽ 0.10) with an were determined by Spearman rank correlation
unpaired Student’s t-test. coefficients. Significance was reported as P ⬍ .05.

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