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A moulded plaster cast is a safe and cost-effective alternative to surgery for a distal radius fracture (a break where the forearm meets the wrist joint). Researchers found casts to be as effective as surgery using wire. Wrist pain and function were similar, regardless of which approach was taken.

A distal radius fracture is common, particularly among older women. If the broken bones remain in the correct alignment, the fracture can be treated with simple wrist support. However, more serious injuries in which the bones have moved out of their usual alignment, usually require hospital treatment. Surgery is effective but also expensive and it carries additional risks. To date, there has been little evidence that casts are an effective alternative to surgery.

This study included people with a serious break (in which bones had moved out of position). They were randomly chosen either to have a plaster cast, or surgery with Kirschner wire (K-wire) to hold the bones in position. The 2 approaches gave similar results. However, in the first 6 weeks, 1 in 8 of those who received a cast needed surgery afterwards (as the bones had moved out of place).

The study followed almost 500 adults for a year after their distal radius fracture. It found that a plaster cast is a good alternative to surgery. The researchers hope their findings will change current practice.

What’s the issue?

Every year in the UK, nearly 100,000 people fracture the distal radius bone. This injury is often associated with falling on an outstretched hand. It is especially common in women over 50 years who are more likely to have osteoporosis (weakened bones). Nearly 1 in 10 women aged 90 will have broken their wrist at some point in their lives.

If the wrist bones have moved out of their normal position, a clinician typically manipulates them to get them back in place. This is painful and people usually need local or general anaesthesia.

The bones then need to be kept in alignment while they heal. Surgery, using K-wires, is one option to keep them in place. A moulded plaster cast is another.

For these fractures (in which bones have moved but can be manipulated back into alignment), the National Institute for Health and Care Excellence (NICE) currently recommends surgery using K-wires. Casts are cheaper than surgery, require shorter anaesthesia and carry fewer risks. However, surgeons may be concerned that casts do not keep the bones in the correct alignment as effectively as surgery. Many prefer to offer surgery rather than a plaster cast.

Previous research comparing surgery with plaster cast is low quality. Before this study, it was not clear which is the more effective approach.

What’s new?

The researchers included 500 adults who were being treated at 36 NHS hospitals. They all had severe distal radius fractures that had not broken the skin. Participants were 60 years old on average and most (83%) were women. They had manipulation to realign their fracture. The researchers then randomly allocated each person either to surgical fixation with wires, or a moulded cast. After 6 weeks, the wires or casts were removed.

At several points in the following year, 395 (79%) participants completed questionnaires, and scored their pain, wrist function and quality of life. The researchers noted complications, including further wrist surgery, and any physiotherapy received.

The study found that:

  • at 1 year, people in both groups showed similar reductions in wrist pain and disability, and improvements in health-related quality of life
  • at 1 year, both groups had improved wrist function but neither group had regained the function they had before their injury
  • within the first 6 weeks, 1 in 8 people in the cast group also needed surgery because the cast did not hold bones in place; only 1 person in the surgery group needed repeat surgery
  • other complications, including blood clots and complex pain, were rare and rates were similar in both groups.

Questionnaires completed at 3, 6 and 12 months showed that participants in both groups had similar recovery times.

The study was part of the wider UK DRAFFT2 project, which included an analysis of costs. The overall cost of treatment with a cast was lower than with surgical fixation. This is despite the fact that 1 in 8 people who had a cast required further treatment in the first 6 weeks.

Why is this important?

This research found that surgery was no more effective than a plaster cast for treating people with a fracture of the distal radius. People had similar improvements in pain and disability, regardless of which treatment they received.

The researchers had expected that more more people given a cast would require further treatment, than those who had surgical fixation. K-wire directly holds bones together, while a plaster cast provides only indirect support outside the skin. As the swelling goes down after the injury, the cast becomes looser and bones are more likely to move out of place. People given a cast should therefore be followed up carefully to check their bones have remained aligned.

Surgery using K-wire, rather than plates and screws, was chosen for this study. Previous research by this team showed that K-wire is as effective as metal plates for people who can be treated without breaking the skin. This work informed NICE guidelines, which now recommend that metal plates are reserved for fractures which need open surgery (in which the skin has to be opened to put the bones back in position). The researchers say, since publication in 2015, surgeons have moved away from using plates, to K-wire, in surgery.

The new findings may encourage clinicians to discuss using a cast as a safe and cost-effective alternative to surgery. People with distal radius fractures need to be fully informed, and understand that they may need surgery later if they have a cast. But casts may come with lower risk than surgery and be more cost-effective for the NHS.

The researchers hope their findings will inform future NICE guidelines. They would like to see recommendations strengthened to clearly suggest that a plaster cast is preferable to K-wire surgery for fractures that can be manipulated back into position. They would like this research to be emphasised in clinical training.

What’s next?

The researchers are now investigating whether their findings are relevant in other countries. They are taking part in a large international analysis of data from individual patients included in previous studies.

One unanswered question is whether people with uncomplicated broken wrists can be kept out of the operating theatre altogether. It could be that they can have a cast applied in a fracture clinic with less or no anesthesia at all. This could potentially have benefits for patients, while also reducing the cost of treatment. The researchers are conducting preliminary research in this area and say that better insight into patients’ preferences is also needed.

This research concentrated on adults. An ongoing study, the Children’s Radius Acute Fracture Fixation Trial (CRAAFT) is comparing casts and surgery for broken wrists in children.

You may be interested to read

This NIHR Alert is based on: Costa ML, and others. Surgical fixation with K-wires versus casting in adults with fracture of distal radius: DRAFFT2 multicentre randomised clinical trial BMJ 2022;376:e068041

The full report on the DRAFFT2 trial: Costa ML, and others. Moulded cast compared with K-wire fixation after manipulation of an acute dorsally displaced distal radius fracture: the DRAFFT 2 RCT. Health Technology Assessment 2022:26:11

Previous report by the same team, comparing K-wires with metal plates: Costa ML, and others. UK DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius. Health Technology Assessment 2015;19:17

NICE guideline [NG38]. 2016: Fractures (non-complex): assessment and management.

A video from the research group summarising the DRAFFT2 trial.

Funding: This project was funded by the NIHR Health Technology Assessment programme.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.


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Comments

Study author

There’s no meaningful difference between the wires and the cast. If you can hold the bones in the right place while they heal, it doesn’t matter whether you put wire in, or use a plaster cast. You achieve the same result. This is obviously good news for patients, because having surgery comes with some risks.

The other important information is that 1 in 8 patients who had a plaster cast, needed further surgery to put the bones back in the right place. People need to need to know that this is a possibility when you are discussing the pros and cons of treatment.

The other side of that, is 7 out of 8 people with a cast did not need further surgery. But surgeons need to keep a careful eye on people, at least for the first 3 weeks after their cast is applied.

Matthew Costa, Professor of Orthopaedic Trauma Surgery, University of Oxford, & Honorary Consultant Trauma Surgeon, John Radcliffe Hospital, Oxford 

Surgeon

Non-operative treatment, by manipulating the fracture into good alignment and then immobilising in a plaster cast, is the standard treatment for most of these injuries. However, there is ever increasing concern that the good positions of the fractures achieved by the manipulation is not maintained with immobilisation in plaster. The fear is that this could give a poor functional outcome with pain, loss of motion and need to rebreak and reset the fracture. As a result, more and more fractures are being treated by manipulation and insertion of Kirschner wires (or plates and screws) to prevent the fracture losing its good position while it heals.

This paper suggests no benefit, in terms of function, to Kirschner wire fixation after manipulation and that it is safe to continue treating these injuries non-operatively in plaster. This will go against the biases and opinions of some orthopaedic surgeons and is an important message.

This is an important study, especially as Kirschner wire insertion requires treatment in an operating theatre whereas treatment in a plaster cast can be performed without incurring the costs associated with a trip to the operating theatre.

Tim Davis, Consultant Trauma and Orthopaedic Surgeon, Nottingham University Hospitals

Nurse

This research will reassure clinicians and patients that routine surgical fixation (with wires or plates) does not improve long-term wrist function following a fracture. The findings will increase confidence in the conservative management of fractures and help inform clinical decision-making.

The study will enable a person-centred approach to care and ensure that best practice and patient outcomes are achieved with the minimal risk to the patient. It will also be useful when educating pre-registration and qualified health professionals. Education needs to be informed by research, and practice to be based on evidence.

Jennie Walker, Principal Lecturer, Institute of Health and Allied Professions, Nottingham Trent University 

Member of the public

I was surprised to see how common this type of injury is in older women.

Sharing the findings could empower people who have broken their wrist. That would be helpful, even if the NHS doesn’t provide a choice of different options. As a patient, I’d like to understand why my Trust had chosen one approach over another.” 

Claire Cooper, Public Contributor, London 

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