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Original Article

Volar Locking Plate versus External Fixation for Distal Radius Fractures:
A Meta-analysis of Randomized Controlled Trials

Abstract Qiang Fu,

Background: Volar locking plate  (VP) and external fixation  (EF) are the two most commonly used Lei Zhu,
methods for treating distal radius fractures. The aim of this study was to identify which of the two Peng Yang1,
treatments leads to better outcomes  (clinically and radiographically) with fewer complications.
Aimin Chen
Materials and Methods: A  metaanalysis was performed. All available randomized controlled
Department of Orthopedic
trials (RCTs) which compared the clinical results of VP to EF were obtained and the reported means
Trauma Surgery, Changzheng
and standard deviations were extracted to perform data synthesis. Results: A  total of 9 published Hospital, Second Military
RCTs with 776  patients fulfilled all inclusion criteria. Data analysis revealed that VP gives better Medical University,
clinical results in the early postoperative period in terms of disabilities of the arm, shoulder, 1
Department of Orthopedics,
and hand  (DASH) scores  (3 and 6  months), grip strength  (3  months), flexion, extension, and The 455th Hospital of Chinese
supination  (3  months). VP is also advantageous over EF regarding the DASH scores, maintenance People's Liberation Army,
Shanghai, China
of ulnar variance, and total and mild surgical complications at 12  months. Conclusions: This
meta analysis supports the use of VP in treating distal radius fractures.

Keywords: Locking plate, external fixation, distal radius fracture, metaanalysis

MeSH terms: Radius, fractures, bone plates, randomized controlled trials topic

Introduction fixation with various forms of implants.10,11

In recent decades, internal fixation with
There is no consensus on the optimal
volar locking plates  (VPs) has become
treatment of distal radius fractures.1
increasingly popular.12 Theoretically,
Methods range from nonoperative
it can provide robust and satisfactory
treatment to external and internal fixation.
stability and reduce the damage of the
Fractures were deemed stable if there was
dorsal extensor tendons due to the volar
an adequate initial reduction, defined as
approach.13 Although different types of
residual dorsal angulation of  <10°  (from
fixation and many case series with good
neutral), loss of height of <2 mm compared
results have been published,14-16 it remains
with the contralateral side, articular step-off
controversial how best to treat distal radius
of  ≤1  mm, and no associated instability of
fractures. Usually, the decision-making and
the distal radio-ulnar joint. These fractures
the management are mainly based on the
can be treated nonoperatively with a
patient characteristics, fracture pattern, and
satisfactory outcome.2,3 For unstable types,
orthopedist’s clinical experience.
if fractures can be reducible to an acceptable Address for correspondence:
position by sustained countertraction using A number of systematic reviews and Dr. Aimin Chen,
metaanalyses conducted to compare Department of Orthopedic
the concept of ligamentotaxis,4 external
Trauma Surgery, Changzheng
fixation  (EF)  (with/without percutaneous external and internal fixation of distal radial Hospital, Second Military
Kirschner-wire)5-8 is an effective way to fractures have been performed before.17-20 Medical University, Shanghai,
treat this kind of trauma with minimal However, some of these studies included China.
retrospective studies and case series, E-mail: aiminchen@smmu.
invasion. However, for some displaced
edu.cn
or comminuted distal radius fractures, it which might result in certain biases. More
is very difficult to obtain and maintain an importantly, for internal fixation, there were
ideal reduction, even with the use of EF. a variety of plates including volar, dorsal, Access this article online
There is a consensus in the literature that and volar combining dorsal plate. The
Website: www.ijoonline.com
these fractures require operative fixation heterogeneity of interventions may also lead
DOI:
such as intramedullary fixation9 and internal to an unreliable conclusion. Walenkamp 10.4103/ortho.IJOrtho_601_16
et  al.21,22 and Li-hai et  al.22 undertook two Quick Response Code:

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the terms of the Creative Commons Attribution-NonCommercial- How to cite this article: Fu Q, Zhu L, Yang P,
ShareAlike 4.0 License, which allows others to remix, tweak, and Chen A. Volar locking plate versus external fixation
build upon the work non-commercially, as long as appropriate credit for distal radius fractures: A meta-analysis of
is given and the new creations are licensed under the identical terms. randomized controlled trials. Indian J Orthop
For reprints contact: [email protected] 2018;52:602-10.

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Fu, et al.: Volar locking plate versus external fixation for distal radius fractures

metaanalysis to compare VP with EF in treating distal skin erythema, transient radial neurapraxia, excessive
radial fractures. In their studies, three and six randomized postoperative pain, and superficial infections not requiring
controlled trials  (RCTs) were included, respectively, and antibiotics,  (ii) moderate complications, defined as those
the relatively small sample sizes of the included studies led with a need for further surgery or intravenous antibiotic
to the limitation. Subsequently, several relevant RCTs were treatment, but not affecting the final outcome, such as
conducted,23-25 but the reported results were inconsistent. CTS and tendonitis requiring surgery, or deep infection
requiring antibiotics,  (iii) severe complications, defined as
Therefore, a more precise updated metaanalysis should be
those influencing the final outcome and in need of surgical
carried out, which will make the result more persuasive.
or other intervention, such as loss of reduction, malunion
In this large scale metaanalysis of RCTs, we aim to
and nonunion requiring additional surgery or splinting,
compare the functional outcomes, radiological parameters,
reflex sympathetic dystrophy, and tendon rupture.29
and complication rate between VP and EF with/without
percutaneous in the treatment of distal radius fractures to RCTs regarding open fractures, retrospective studies,
improve our understanding and guide our management of biomechanical studies, literature reviews and the studies
this condition. that did not provide sufficient data, such as the patients’
demographic characteristic or the information on surgery,
Materials and Methods diagnosis, followup, clinical outcomes and complications,
were all excluded. Trials that compared different internal
Search strategy fixation techniques or other implants were also excluded.
The systematic review was performed following the Data extraction and quality assessment
Preferred Reporting Items for Systematic Reviews and
MetaAnalyses (PRISMA) statement.26,27 The English All eligible studies were reviewed, and the reported means
language literature search was performed on PubMed and standard deviations were extracted independently by
and the Cochrane Central Register of Controlled Trials 2 reviewers using a data collection form. Extracted data
(1980 to December 2015) using the following Medical included patient characteristics (sample size, mean age, the
Subject Heading items in different combinations: distal proportion of females), fracture types  (AO classification),
radius fracture, VP, EF, treatment outcome, comparative protocol for the treatment of fractures, followup length,
study, and randomized trial. To identify other relevant outcome measures, and complications. If standard
studies, we also reviewed the references from the identified deviations were not reported and could not be calculated
trials and review articles. Only those with full text available from available data, we asked authors to supply the data.
were considered. Quality assessment was judged on concealment of treatment
allocation; similarity of both groups at baseline regarding
Study selection
prognostic factors; eligibility criteria; blinding of outcome
We have included articles based on the following inclusion assessors, care providers, and patients; completeness of
criteria: (1) RCTs assessing VP versus EF (with or without followup; and intention-to-treat analysis. We quantified
supplementary percutaneous pinning) in treating closed study quality using the Modified Jadad score [Table 1].30 A
distal radius fractures;  (2) studies reported at least 1 of third reviewer adjudicated any disagreement about extracted
the following outcomes of interest: patient-rated functional data and checked the extracted data for accuracy. The
outcome instrument scores disabilities of the arm, shoulder data were entered into the Review Manager  (Version  5.2.
and hand  (DASH); grip strength; wrist flexion and Copenhagen: The Nordic Cochrane Centre, The Cochrane
extension, forearm supination and pronation, ulnar deviation Collaboration, 2008) database for further analysis.
and radial deviation; radiograph-based parameters and rates
Data analysis
of complications. The primary outcome measure of this
metaanalysis was the DASH score at 3, 6, and 12  months Continuous variables  (DASH scores, grip strength, ROM,
followup. This is a validated self-reported, 30-item and radiographic parameters) were analyzed using the
questionnaire designed to measure the upper extremity weighted mean differences with its 95% confidence
function and symptoms in fracture patients, with the total interval (CI), whereas dichotomous data (complication rate)
scale score ranging from 0 (no disability) to 100 (maximum was analyzed using the risk ratio  (RR) measure with its
disability).28 The secondary outcome measures were: 95% CI. Moreover, statistical heterogeneity across trials
(1) grip strength and the range of motion (ROM) of injured was quantified with I 2 statistic conforming to PRISMA
wrist reported as a percentage of the uninjured side at 3, guidelines.26 I 2 value  <25% was considered homogeneous,
6, and 12  months followup;  (2) radiographic parameters at I 2 values of 25%, 50%, and 75% or more represent low,
12  months followup; and  (3) complication rate. According moderate, and high heterogeneity, respectively.31 If the
to their different extent of severity, complications studies were homogeneous or the statistical heterogeneity
were divided into  (i) mild complications, defined as was low, a fixed-effect model was used to assess the overall
temporary and self-healing, such as transient carpal tunnel estimate. Otherwise, a random-effect model was chosen.32
syndrome  (CTS) and tendonitis not requiring surgery, Sensitivity analyses (exclusion of one study at a time) were

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Fu, et al.: Volar locking plate versus external fixation for distal radius fractures

Table 1: Modified Jadad score

Items Score standard Score
0 1 2
Randomization Not randomized or inappropriate The study was described as The method of randomization was
method of randomization randomized described and it was appropriate
Concealment of Not describe the method of The study was described as using The method of allocation
allocation allocation concealment allocation concealment method concealment was described
appropriately
Double blinding No blind or inappropriate The study was described as The method of double blinding was
method of blinding double-blind described and it was appropriate
Withdrawals Not describe the followup A description of withdrawals and
and dropouts dropouts
Total

conducted to assess heterogeneity and robustness of pooled P  =  0.14; I² = 49%, respectively) at 6 and 12  months of
results. We assessed for potential publication bias using a followup between this two treatment arms, so no method
funnel plot. All tests were two-tailed and a P <  0.05 was was favored [Figure 2].
considered as statistically significant in this meta-analysis.
Metaanalysis of range of motion
Results ROM data  (expressed as a percentage of the contralateral
Literature search uninjured wrist) including flexion, extension, pronation,
supination, radial deviation, and ulnar deviation that were
All potentially relevant articles and abstracts were pooled across six studies are summarized in Table  3.
reviewed, of which 9 published RCTs23-25,33-38 with a total Analysis of these data revealed that compared with EF
of 776  patients fulfilled all inclusion criteria for our meta- group, the pooled treatment effect regarding flexion,
analysis. The included study characteristics are summarized extension and supination ability was statistically superior
in Table  2, exhibiting the information of authors, year of (mean difference  =  5.99; 95% CI: 0.62–11.35; P =  0.03,
publication, patient age range, sample size, fracture types, I² =57%, mean difference  =  10.90; 95% CI: 1.50–20.30;
intervention forms, length of the followup period, and P  =  0.02; I² = 79% and mean difference  =  4.82; 95%
Jadad scores. CI: 0.53–9.11; P =  0.03; I² = 34%, respectively) at
Meta-analysis of disabilities of the arm, shoulder and 3  months followup among patients in VP group. And a
hand scores statistically significant difference in ulnar deviation was
found at 6  months postoperatively in favor of EF  (mean
Four studies with 304  patients  (VP, n  =  150; EF, difference = −5.59; 95% CI: −8.84 to  −2.35; P =  0.0007;
n  =  154) independently reported the patients’ self- I² = 0%). No other ROM parameters revealed any
reported outcome-DASH scores. The analysis revealed a significant differences in treatment effect between the two
significant difference in pooled treatment effect favoring groups at any interval time after fixation.
VP at 3  months followup  (mean difference = −12.96;
95% CI: −21.11 to  −4.82; P =  0.002; I 2  =  77%). Similar Metaanalysis of radiographic parameters
significant results were obtained at 6  months  (mean Five studies with 350  patients  (VP, n  =  172; EF, n  =  178)
difference = −6.20; 95% CI: −9.83 to  −2.58; P =  0.0008; reported the volar tilt, three with 185  patients (VP, n  =  87;
I² = 0%), as well as at 12  months postoperatively  (mean EF, n  =  98) reported the radial inclination and two
difference = −6.39; 95% CI: −11.91 to  −0.87; P =  0.02; with 111  patients  (VP, n  =  51; EF, n  =  60) reported the
I 2 = 62%) [Figure 1]. radial length at 12  months followup. Metaanalysis of
Metaanalysis of grip strength these three parameters showed no significant difference
between the two methods compared. However, parameters
Grip strength values  (measured as a percentage of the regarding ulnar variance pooled across three studies with
contralateral uninjured wrist) were pooled across eight 185  patients  (VP, n  =  87; EF, n  =  98) revealed significant
studies with 665  patients  (VP, n  =  322; EF, n  =  343). At differences with smaller ulnar variance in VP group
3  months, we found significant superior grip strength in (Mean difference = −0.82; 95% CI: −1.39 to  −0.25;
patients receiving the treatment of VP compared with P = 0.005; I² = 0%) at 12 months after fixation [Table 4].
those receiving EF  (mean difference  =  14.19; 95% CI:
Metaanalysis of complications
7.65–20.73; P <  0.0001; I 2  =  63%). However, analysis
for grip strength revealed no significant difference  (mean All the 9 eligible studies with 776  patients provided
difference  =  3.46; 95% CI: −3.76–10.68; P =  0.35; information on surgical complications. In total, a
I² = 81% and mean difference = 3.38; 95% CI: −1.14–7.90; complication rate of 21.39% in the VP group and 27.86%

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Fu, et al.: Volar locking plate versus external fixation for distal radius fractures

Table 2: Characteristics of included studies

Authors, Study Number Female Mean age±SD (range), AO Intervention type Followup Jadad
year design of fracture proportion, year (VP/EF) classification VP EF time score
(VP/EF) % (VP/EF) of fracture
Egol RCT 44/44 39/38 52.2 (19-87)/49.9 (18-78) ABC Locked Bridging EF 2 and 6
et al., 2008 volar plate (±K-wire) 6 weeks
and 3, 6 and
12 months
Wei RCT 12/22 75/72 61±18/55±16 A3 C1-3 Locked Bridging external 6 weeks 6
et al., 2009 volar plate fixator + K-wires and 3, 6 and
12 months
Wilcke RCT 33/30 76/77 55 (20-69)/56 (21-69) A C1 Volar Bridging 10 days, 5
et al., 2011 locked external fixator 5 weeks,
plate (±K-wires) and 3, 6 and
12 months
Jeudy RCT 36/39 72/79 64.7±3.7/64.6±3.5 C2 C3 Volar External fixator 3, 6, 12 and
4
et al., 2012 locked (±pins) 24 weeks
plate
Gradl RCT 52/50 87 63 (18-88) A3 C1-3 Volar fixed Nonbridging 8 weeks, 6 4
et al., 2013 angle plate external fixator months and
(±K-wires) 1 year
Karantana RCT 66/64 61/78 48±15/51±16 A3 C2 C3 VP K-wires±bridging 6, 12 weeks 4
et al., 2013 external fixator and 1 year
Williksen RCT 52/59 80 54 (20-84) A2-3 C1-3 Volar External fixator 6, 16, 2
et al., 2013 locked and K-wires 26 and
plate 52 weeks
Roh RCT 36/38 30/36 54.4±10.9/55.3±11.2 C2 C3 VP Bridging external 3, 6 and 12 5
et al., 2014 fixator + K-wires months
Shukla RCT 48/62 58/53 39.33±13.1/38.95±13.1 C Volar Bridging external 6 months 3
et al., 2014 locked fixator and 1 year
plate
RCT=Randomized controlled trial, VP=Volar locking plate, EF=External fixation, SD=Standard deviation, AO=Arbeitsgemeinschaft für
Osteosynthesefragen

Table 3: Range of motion at 3, 6, and 12 months followup

Followup time Clinical outcome (%) Studies Fractures MD 95% CI P Favored
VP EF
3 months Flexion 5 186 192 5.99 0.62-11.35 0.03 VP
Extension 4 150 154 10.90 1.50-20.30 0.02 VP
Pronation 4 153 162 3.42 −2.99-9.83 0.30 -
Supination 3 117 124 4.82 0.53-9.11 0.03 VP
Ulnar deviation 2 51 60 −0.11 −3.67-3.54 0.95 -
Radial deviation 2 51 60 8.70 −34.40-51.80 0.69 -
6 months Flexion 5 172 178 4.26 −2.49-11.01 0.22 -
Extension 4 136 140 9.73 −6.40-25.85 0.24 -
Pronation 3 87 98 12.44 −4.40-29.29 0.15 -
Supination 3 103 110 1.90 −2.64-6.44 0.41 -
Ulnar deviation 3 103 110 −5.59 −8.84-−2.35 0.0007 EF
Radial deviation 3 103 110 −5.97 −21.49-9.55 0.45 -
12 months Flexion 6 238 242 −0.12 −2.56-2.32 0.92 -
Extension 5 202 204 0.95 −3.53-5.43 0.68 -
Pronation 4 153 162 0.71 −2.94-4.37 0.70 -
Supination 4 169 174 −0.54 −1.96-0.87 0.45 -
Ulnar deviation 3 103 110 −0.68 −3.85-2.49 0.68 -
Radial deviation 3 103 110 −3.53 −7.26-0.20 0.06 -
VP=Volar locking plate, EF=External fixation, MD=Mean difference, CI=Confidence interval

in the EF group was found from the pooled result. The compared to EF, there was a statistically significant
metaanalysis for overall complication rate revealed that, difference favoring VP  (RR  =  0.75; 95% CI: 0.58–0.95;
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Fu, et al.: Volar locking plate versus external fixation for distal radius fractures

Figure 1: Table and forest plot illustrating mean difference in disabilities of the arm, shoulder and hand scores at 3, 6, and 12 months followup between
volar locking plate and external fixation

Table 4: Radiological outcomes at 12 months followup Discussion

Radiological Studies MD (95% CI) P Favored This metaanalysis represents 9 RCTs of VP versus EF,
outcome
which is the largest sample size to date analyzing the
Volar tilt (degree 5 1.46 (−4.13-7.04) 0.61 -
treatment effect of these two procedures. According to the
from neutral)
Radial inclination (°) 3 −0.95 (−3.60-1.69) 0.48 -
best estimates from our metaanalysis, management with VP
Radial length (mm) 2 −0.96 (−1.96-0.04) 0.06 - leads to lower DASH scores compared to EF throughout
Ulnar variance (mm) 3 −0.82 (−1.39-−0.25) 0.005 VP the 12  month followup period. These results are similar
CI=Confidence interval, MD=Mean difference, VP=Volar locking to the findings of Wang et  al.19 but different from the
plate 12 month outcomes of Xie et al.20
To fully appreciate the findings, we analyzed the clinical
P  =  0.02; I² = 0%) during the followup period  [Figure  3]. relevance of the differences of DASH scores to make the
Further analyses  [Figure  4] also indicated that mild
statistical differences more meaningful and practical. The
complications in VP group were statistically less than in EF
minimal clinically important difference in DASH scores
group (RR = 0.55; 95%CI: 0.39–0.79; P = 0.001; I² = 0%),
for the wrist pathology ranges from 10 to 15 points.21,28
whereas no significant difference in moderate and severe
Results of the analysis showed that the difference was
complications was detected (RR = 1.12; 95% CI: 0.69–1.82;
12.96 at 3 months, which was within that range. Hence, this
P  =  0.65; I² = 18% and RR  =  1.12; 95% CI: 0.60–2.08;
P = 0.72; I² = 27%, respectively). difference in favor of VP at 3  months should be considered
not only statistically significant but also clinically relevant for
Sensitivity analysis and publication bias analysis the patients. For VP, direct visualization and manipulation of
For the purpose of investigating the potential publication the bone fragments could provide better anatomic restoration
bias, funnel plots based on the results of complication data and stable rigid fixation, which could make it possible for
was graphed and the funnel plot did not reveal obvious immediate wrist postoperative active motion and excellent
asymmetry. The robustness of results was assessed by the prognosis in initial stage. Interestingly, the differences at 6
performing of sensitivity analyses, which demonstrated that and 12  months while still statistically significant, no longer
no individual study affected the overall RR predominantly. meet the clinically relevant difference noted above.

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Fu, et al.: Volar locking plate versus external fixation for distal radius fractures

Figure 2: Table and forest plot illustrating mean difference in Grip strength (measured as a percentage of the uninjured wrist) at 3, 6, and 12 months
followup between volar locking plate and external fixation

Figure 3: Table and forest plot illustrating risk ratio in total surgical complications at 12 months followup between volar locking plate and external fixation

As compared to the EF group, pooled data from the treatment of VP led to superior performance in terms of the
eligible studies revealed that distal radial fractures with the recovery of grip strength, flexion, extension, and supination

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Figure 4: Table and forest plot illustrating risk ratio in mild surgical complications at 12 months followup between volar locking plate and external fixation

at 3  months. No significant difference was found at 6 or In our metaanalysis, there were 3 studies24,25,38 focused
12  months followup period. Delayed wrist functional only on displaced intraarticular  (AO type  C) fractures. The
exercise in EF group may explain the disadvantage over intraarticular distal radius fracture is a very common type
VP group in early time. Patients in EF group began to take which occupies 10% to 12% of whole fractures and 77%
functional exercises after the removal of external fixator at of this complicated fracture accompanies the sigmoid notch
approximately 6–8  weeks after the operation. Only from involvement.42,43 Shukla24 showed that EF had superiority
then on the grip strength began to recover and the initial over VP at outcome at 1-year followup. However, patients
weakness and stiffness gradually improved. As a result, in his study were relatively young. On the contrary,
the differences were not significant at 6 and 12  months. Jeudy et al.38 and Roh et al.25 both found VP had superior
Besides, the analysis reveals that EF led to significantly radiological outcome and better functional recovery without
better ulnar deviation at 6 months followup. The difference provoking further complications. We prefer to support
was, however, small and the overall ulnar deviation results the latter because we believe that direct manipulation and
equalized at 12 months. Therefore, the clinical relevance of fixation of bone fragments may be better for restoring
this difference at 6 months remains uncertain. articular congruence of the distal end of the radius.
Radiographic assessment of volar tilt, radial inclination, Our metaanalysis found that VP led to fewer total and
radial length, and ulnar variance was compared to published mild surgical complications at 12  months followup. In the
norms18,39,40 to assess the accuracy and the stability of the metaanalysis of Walenkamp et  al. in 2013 and Xie et  al.
reduction. Late collapse of fixation, which is an important in 2013, they reported similar outcomes that there seemed
inducing factor of malunion, will occur in a considerable to be a slight trend for patients treated with VP to suffer
number of cases even though there was good initial fewer complications than those treated with EF. However,
anatomic reduction, especially in EF. Kawaguchi et  al.41 no significant difference was found between the two groups
have reported in their study that secondary displacements at final followup, which was different from our results.
occurred in more than 50% of the cases when EF was used. Considering that all the 9 RCTs with large sample size
Our analysis revealed that VP demonstrated significantly included in our metaanalysis recorded the complication
less ulnar positive variance than EF at 12 months. However, rate, funnel plot, and sensitivity analysis indicating the
this difference in ulnar positive variance did not translate to study was robust and reliable, we have reasons to believe
a statistical advantage in radial length or radial inclination. our results are more precise and the complication rate is
No significant loss of reduction with either treatment after indeed lower with VP than EF at 12 months.
the last followup means EF actually will not increase the Several limitations exist in this metaanalysis, the results of
risk of late collapse compared with VP. In Walenkamp our study should be interpreted with caution. The first is
et  al.’s study,21 a significant difference in volar tilt was the potential study heterogeneity regarding mean patient
observed in favor of treatment with a VP. However, that age, the proportion of women and different fracture types.
was not detected in our metaanalysis. The explanation for We could not completely match the cohorts to conduct the
this result could be that when we analyzed these parameters, subgroup analysis. Besides, we did not study treatment
there was a lack of eligible study and the sample size was cost, which is a subject of current debate. In addition, the
relatively small. Hence, the estimation may be less precise, varied surgeons with different levels of surgical experience
and the data should be interpreted with caution. among the included studies could also influence the results.

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Fu, et al.: Volar locking plate versus external fixation for distal radius fractures

It is worth pointing out distal radius fracture with the 2. Simic  PM, Weiland  AJ. Fractures of the distal aspect of the
involvement of the volar ulnar fragment, also known as the radius: Changes in treatment over the past two decades. Instr
Course Lect 2003;52:185-95.
“critical corner,” is a special kind of fracture.44 Failure to
3. Jupiter  JB. Fractures of the distal radius. Surg Annu 1992;24
reduce this fragment can lead to instability at joint surface (Pt 1):143-60.
and malunion may occur. Due to its unique anatomy, EF 4. Siripakarn  Y, Siripakarn  Z. Multipurpose external fixator
alone cannot provide rigid fixation. To maintain reduction, for intraarticular fracture of distal radius. J  Med Assoc Thai
some of the included RCTs used EF with temporary 2010;93 Suppl 7:S324-31.
subchondral K-wires to secure volar ulnar fragment. 5. Haddad  M, Rubin  G, Soudry  M, Rozen  N. External fixation
However, they did not carry out separate analysis of the for the treatment of intraarticular fractures of the distal radius:
outcome of this type of fracture. To avoid these limitations, Short-term results. Isr Med Assoc J 2010;12:406-9.
more RCTs with higher methodological qualities are needed 6. Habernek H, Weinstabl R, Fialka C, Schmid L. Unstable distal radius
fractures treated by modified kirschner wire pinning: Anatomic
to obtain more convincing evidence. considerations, technique, and results. J Trauma 1994;36:83-8.
In summary, the findings of this metaanalysis favor VP 7. Kamiloski  V, Kasapinova  K. External fixation in patients
for improved early clinical outcomes including DASH with age over  65  years with distal radius fracture. Prilozi
2006;27:189-99.
scores, grip strength, flexion, extension, and supination,
8. Dicpinigaitis  P, Wolinsky  P, Hiebert  R, Egol  K, Koval  K,
suggesting that it is likely to facilitate a more rapid Tejwani  N, et al. Can external fixation maintain reduction after
functional recovery which may be advantageous for distal radius fractures? J Trauma 2004;57:845-50.
specific patients who desire an accelerated return of 9. Nishiwaki M, Tazaki K, Shimizu H, Ilyas AM. Prospective study
function. In the long run, IF is also advantageous over of distal radial fractures treated with an intramedullary nail.
EF regarding the DASH scores, maintenance of ulnar J Bone Joint Surg Am 2011;93:1436-41.
variance and the total and mild surgical complications. 10. Kawasaki  K, Nemoto  T, Inagaki  K, Tomita  K, Ueno  Y.
Variable-angle locking plate with or without double-tiered
Hence, we support the use of VP in the management of
subchondral support procedure in the treatment of intraarticular
distal radius fractures. distal radius fracture. J Orthop Traumatol 2014;15:271-4.
11. Wong  KK, Chan  KW, Kwok  TK, Mak  KH. Volar fixation
Conclusions of dorsally displaced distal radial fracture using locking
In summary, the findings of this metaanalysis favor VP in compression plate. J Orthop Surg (Hong Kong) 2005;13:153-7.
early postoperative period in terms of DASH scores, grip 12. Orbay  JL, Fernandez  DL. Volar fixation for dorsally displaced
fractures of the distal radius: A  preliminary report. J  Hand Surg
strength, flexion, extension and supination, suggesting that Am 2002;27:205-15.
it is likely to facilitate a more rapid functional recovery 13. Kandemir  U, Matityahu  A, Desai  R, Puttlitz  C. Does a volar
which may be advantageous for specific patients who desire locking plate provide equivalent stability as a dorsal nonlocking
an accelerated return of function, like the young or the plate in a dorsally comminuted distal radius fracture? A
athletes. In the long run, IF is also advantageous over EF biomechanical study. J Orthop Trauma 2008;22:605-10.
regarding the DASH scores, maintenance of ulnar variance 14. Missakian  ML, Cooney  WP, Amadio  PC, Glidewell  HL. Open
and the total and mild surgical complications. Hence, we reduction and internal fixation for distal radius fractures. J  Hand
Surg Am 1992;17:745-55.
fairly support the use of VP in the management of distal
15. Rikli DA, Küpfer K, Bodoky A. Long term results of the external
radius fractures. fixation of distal radius fractures. J Trauma 1998;44:970-6.
Declaration of patient consent 16. Young  BT, Rayan  GM. Outcome following nonoperative
treatment of displaced distal radius fractures in low-demand
The authors certify that they have obtained all appropriate patients older than 60 years. J Hand Surg Am 2000;25:19-28.
patient consent forms. In the form the patient(s) has/have 17. Margaliot  Z, Haase  SC, Kotsis  SV, Kim  HM, Chung  KC.
given his/her/their consent for his/her/their images and A  meta-analysis of outcomes of external fixation versus plate
other clinical information to be reported in the journal. The osteosynthesis for unstable distal radius fractures. J  Hand Surg
Am 2005;30:1185-99.
patients understand that their names and initials will not
18. Cui  Z, Pan  J, Yu  B, Zhang  K, Xiong  X. Internal versus external
be published and due efforts will be made to conceal their fixation for unstable distal radius fractures: An up-to-date
identity, but anonymity cannot be guaranteed. meta-analysis. Int Orthop 2011;35:1333-41.
Financial support and sponsorship 19. Wang  J, Yang  Y, Ma  J, Xing  D, Zhu  S, Ma  B, et al. Open
reduction and internal fixation versus external fixation for
Nil. unstable distal radial fractures: A  meta-analysis. Orthop
Traumatol Surg Res 2013;99:321-31.
Conflicts of interest 20. Xie X, Xie X, Qin H, Shen L, Zhang C. Comparison of internal
and external fixation of distal radius fractures. Acta Orthop
There are no conflicts of interest.
2013;84:286-91.
21. Walenkamp  MM, Bentohami  A, Beerekamp  MS, Peters  RW,
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610 Indian Journal of Orthopaedics | Volume 52 | Issue 6 | November-December 2018