LNSLNS

We like to thank our colleagues Prantl et al., Artmann and Maier for their constructive criticism. With regard to aftercare, active physiotherapy started after two weeks in the surgical treatment arm. Patients began with finger movements on the first postoperative day and a removable dorsal plaster splint was applied for two weeks. All patients were shown how to perform an exercise program at home and instructions for independent training were handed out. In the plaster cast treatment arm, active physiotherapy started at six weeks. At 3 months the surgical treatment arm showed superior wrist mobility; it is likely that the earlier start of physiotherapy/home program significantly contributed to this outcome. At 12 months, both treatment arms showed comparable wrist mobility and the number of physiotherapy prescriptions had no direct influence on the range of motion achieved.

A preoperative CT scan was performed in addition to standard radiographic studies to optimize treatment planning, where necessary. Postoperatively, no routine CT scan was performed. At 12 months, the superior restoration of radiologic anatomy achieved with locking plate fixation compared with plaster cast treatment (1) was not associated with significantly better wrist mobility and daily-living function. To answer the question whether the superior restoration of joint anatomy will ultimately translate into long-term gains in wrist function and patient satisfaction, a long-term follow-up study is required.

In our study, the rate of complications and severe adverse events was lower than the one reported in the literature, even though in the ORCHID study the procedures were performed by surgeons of all training levels. Remarkably, only one case of CRPS (Sudeck's atrophy) was observed after plaster cast treatment. A positive correlation between higher-degree damage to the articular surface and metaphysis and an increase in the rate of secondary conversion to surgical treatment was found. In our opinion, not only the vast majority of non-displaced distal radius fractures but most displaced fractures where it is possible to largely stabilize the reduction with cast immobilization can be managed with plaster cast treatment until healing is complete (2, 3).

Since over the last decades a significant increase in the average activity levels of elderly patients has been observed, a patient’s individual functional requirements should guide the decision on which treatment to select to manage a wrist fracture.

DOI: 10.3238/arztebl.2015.0487b

PD Dr. med. Christoph Bartl
Klinik für Unfall-, Hand-,
Plastische und Wiederherstellungschirurgie
Universität Ulm
chbartl@gmx.de

PD Dr. med. Dirk Stengel MSc
Zentrum für klinische Forschung
Unfallkrankenhaus Berlin

Dr. sc. hum. Thomas Bruckner
Institut für Medizinische Biometrie und Informatik (IMBI)
Universität Heidelberg

Prof. Dr. med. Florian Gebhard
Klinik für Unfall-, Hand-,
Plastische und Wiederherstellungschirurgie
Universität Ulm

Conflict of interest statement
PD Dr. Stengel has received payments for consultation, reimbursement of congress attendance fees, and honoraria for preparation of scientific meetings from Biomet, Stryker, and the AO Foundation.

He has received reimbursement of travel or accommodation costs from Biomet, Stryker, the AO Foundation, the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie e.V., DGU), and the German Social Accident Insurance (Deutsche Gesetzliche Unfallversicherung,DGU).

PD Dr. Bartl, Dr. Bruckner and Prof. Gebhard declare that no conflict of interest exists.

1.
Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC: A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am 2011; 36: 824–35 CrossRef MEDLINE PubMed Central
2.
Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M: A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am 2011; 93: 2146–53 CrossRef MEDLINE
3.
Bartl C, Stengel D, Bruckner T, Gebhard F and the ORCHID Study Group: The treatment of displaced intra-articular distal radius fractures in elderly patients—a randomized multi-center study (ORCHID) of open reduction and volar locking plate fixation versus closed reduction and cast immobilization. Dtsch Arztebl Int 2014; 111: 779–87 VOLLTEXT
1.Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC: A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am 2011; 36: 824–35 CrossRef MEDLINE PubMed Central
2.Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M: A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am 2011; 93: 2146–53 CrossRef MEDLINE
3.Bartl C, Stengel D, Bruckner T, Gebhard F and the ORCHID Study Group: The treatment of displaced intra-articular distal radius fractures in elderly patients—a randomized multi-center study (ORCHID) of open reduction and volar locking plate fixation versus closed reduction and cast immobilization. Dtsch Arztebl Int 2014; 111: 779–87 VOLLTEXT

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