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Abstract

Background

External fixation for geriatric C-type distal radius fractures (DRF) often restricts early wrist motion. This study compares a strategy of early mobilization after 3–4 weeks of external fixation with lightweight support against the conventional approach of 6–7 weeks of continuous external fixation.

Methods

A total of 174 patients aged 60 or older with C-type DRF were included. They were assigned to either an early mobilization group (n = 86), where external fixation was replaced with a lightweight support at 3–4 weeks, or a control group (n = 88) with conventional 6–7 weeks of external fixation. Outcomes included radiographic measures, functional scores (Gartland-Werley and Quick DASH), and satisfaction.

Results

At week 7, no significant difference in radiographic data was observed between groups (all P > 0.05). At month 12, the control group showed better radiographic outcomes (P = 0.03). The early mobilization group had better functional scores at week 7 for both Gartland-Werley (P = 0.01) and Quick DASH (P = 0.02) compared to the control group. At 6 and 12 months, no significant differences were found between groups in either score (all P > 0.05). Patient satisfaction was significantly higher in the early mobilization group (P < 0.001). There were no significant differences in complication rates (P = 0.13).

Conclusion

Transitioning to early mobilization after 3–4 weeks of external fixation facilitates earlier functional recovery and improves patient satisfaction compared to prolonged immobilization, despite a slight increase in ulnar variance that did not impact functional outcomes.

Keywords

distal radius fracture external fixation early mobilization rehabilitation geriatric trauma

Introduction

Distal radius fractures (DRFs) have a high prevalence in the elderly population, accounting for approximately 12.1% of all traumatic fractures.¹ In light of the demographic shift towards an aging population, it can be reasonably anticipated that the incidence of DRF will continue to increase.^2,3 This type of fracture is typically precipitated by the contact of the wrist with the ground, which may result from a fall or external impact. Its pathogenesis involves intricate biomechanical factors and the structural properties of the bone, which has been a subject of intense clinical investigation.^4–7 The majority of patients with DRF can achieve a satisfactory outcome with conservative treatment.⁸ However, for complex fractures involving articular surfaces, such as C-type DRFs, there is a consensus among scholars that surgical treatment is the optimal approach.^9–13 A variety of surgical techniques are available, including Kirschner wire fixation intramedullary nail fixation, plate fixation, and external fixation.^14–18 In the immediate aftermath of the injury, external fixation becomes the most common surgical procedure. This is due to the necessity of evaluating the patient’s soft tissue condition, physical status, and the urgent need for surgery.^19,20

This study was conducted on 174 patients with C-type DRF admitted to the Department of Orthopedics and Traumatology of Hubei Provincial Hospital of Traditional Chinese Medicine between April 2017 and April 2022. The patients were treated with external fixation. Some patients underwent early removal of their external fixation devices and were subsequently fitted with small splints to facilitate wrist exercises. The remainder of the patients continued with external fixation until the conclusion of their treatment. We conducted a retrospective analysis to evaluate whether early transition from rigid external fixation to a phase of controlled mobilization could improve early functional outcomes and patient experience without compromising fracture stability.

Materials and methods

Patient selection

A total of 200 patients with C-type DRF who met the inclusion criteria were initially enrolled in this study between April 2017 and April 2022. This study was approved by the Ethics Committee of our hospital (Approval Number: HBZY2024-C114-01) and was conducted in accordance with the Declaration of Helsinki. All patients underwent external fixation within 24 h of injury and were over the age of 60. During the 12 to 36-months follow-up period, 26 patients (14 in the early mobilization group and 12 in the control group) were lost to follow-up. Consequently, the final analysis was performed on a Per-Protocol Set (PPS) of 174 patients (86 in the early mobilization group and 88 in the control group) who completed the entire follow-up and did not deviate from the study protocol. At 3 to 4 weeks postoperatively, the method of immobilization was readjusted to small splints or continued with external immobilization until the conclusion of the entire course of treatment. Patients with pathological fractures, open fractures, and a history of wrist fracture surgery were excluded.

General information

A total of 174 DRF patients were divided into two groups based on the duration of postoperative external fixation: a early mobilization group and a control group. The study included 86 patients in the early mobilization group, with 40 males and 46 females. The age range was 60 to 86 years, with an average age of 69.6 years. According to the AO/OTA classification system, 26 cases (30.2%) were classified as type C1, 35 cases (40.7%) as type C2, and 25 cases (29.1%) as type C3. The number of left-handed and right-handed DRF cases was 38 and 48, respectively. The patients in question received external fixation an average of 10.5 h after the injury and had the external fixation device replaced with small splints at 3 to 4 weeks (mean 24.5 days) postoperatively. They continued to be fixed for 2 to 3 weeks (mean 17.4 days). The control group included 88 cases, with 40 males and 48 females. The age range was 60 to 87 years, with an average age of 70.4 years. According to the AO/OTA classification system, 21 cases (23.9%) were classified as type C1, 38 cases (43.2%) as type C2, and 29 cases (32.9%) as type C3. The number of left-handed and right-handed DRF cases was 37 and 51, respectively. These patients received external fixation an average of 11.3 h after injury, but they did not have the external fixation device removed until 6 to 7 weeks (mean 44.1 days) postoperatively. There was no statistically significant difference in the pre-treatment clinical data between the two groups (all p > 0.05) (Table 1).

Table 1.

Demographic, injury, and treatment data of patients with DRF in the early mobilization group and the control group.

	Early mobilization group (n = 86)	Control group (n = 88)
1. Age at injury (years)
Average of age^a	69.62 ± 5.98	70.44 ± 5.80
Range of age	60∼86	60∼87
2. Time from injury to surgery (hours)^a	10.52 ± 5.31	11.31 ± 4.60
3. Gender (No. Patients)
Female^b	46	48
Male^b	40	40
4. Fracture side (No. Patients)
Left^b	38	37
Right^b	48	51
5. AO classification (No. Patients)
C1^b	26	21
C2^b	35	38
C3^b	25	29

^aThe values are given as the mean and SD.

^bThe values are given as the number with the percentage in parentheses.

Surgical technique

Brachial plexus anesthesia was employed during the procedure. Once the anesthesia was deemed satisfactory, the patient was placed in the supine position and the affected limb was placed on a surgical extensor table. A standard surgical preparation procedure was followed, which involved the routine disinfection of the patient’s affected arm and the application of a sterile towel. A tourniquet was then applied to control bleeding. Two small incisions, approximately 0.5 cm in length, were initially made on the dorsal aspect of the second metacarpal bone of the hand. Thereafter, the fixation pins were screwed in sequentially with an electric drill. Next, we made two incisions on the radial side of the dorsal forearm, approximately 1.0 cm, and screwed in the fixation pins. A fluoroscopic examination was conducted using a C-arm X-ray machine to verify the correct positioning of the four fixation pins. Subsequently, a manipulative repositioning procedure was conducted, during which the assistant works with the operator in opposition to traction. This process typically lasts between 3 and 5 table min. The fracture was repositioned, the external fixation device was fixed, and fluoroscopy was performed again using a C-arm X-ray machine to assess the fracture reduction and the degree of correction of radial shortening. The fluoroscopic findings are employed to ascertain the necessity of lengthening the external fixation and to determine whether the palmar tilt angle and radial inclination angle should be adjusted to correct any deformities and restore the anatomical shape of the carpal plane.

Postoperative rehabilitation

Patients in the early mobilization group began functional exercises on postoperative day 2. At 3–4 weeks, the external fixator was removed and replaced with a lightweight, adjustable support that permitted limited wrist motion while maintaining alignment. This support consisted of palmar and dorsal pads secured with flexible straps, allowing controlled mobility and facilitating hygiene (Figure 1). Patients were encouraged to perform gradual wrist motions under guidance. A representative case is illustrated in Figure 2: Preoperative radiographs of a 66-year-old male with a C2 distal radius fracture demonstrated comminuted articular involvement (Figure 2(a)). Postoperative day 2 imaging confirmed satisfactory reduction of the fracture, restoration of radial length, and correction of articular alignment (Figure 2(b)). The patient was instructed to perform small dorsiflexion and palmar flexion exercises of the wrist and to strengthen the hand with fist-making and hand-stretching exercises. The patient was instructed to continue immobilization with small splints for a period of 2 to 3 weeks. The patients in the control group also initiated functional exercises, including fist-making and hand stretching, on the 2nd postoperative day. The external fixation device was removed 6 to 7 weeks after the operation, and the patients were instructed to perform small-amplitude dorsiflexion and palmar flexion exercises of the wrist and to strengthen the fist-making and hand-stretching exercises.

Figure 1.

(a) Materials needed for small splint fixation; (b) Suspension view of small splints after removal of the external fixation device on postoperative day 21; (c) Frontal view of small splints after removal of external fixation on postoperative day 21; (d) Lateral view of small splints after removal of external fixation on postoperative day 21.

Figure 2.

(a) Preoperative frontal and lateral radiographs of the left wrist joint in a 66-year-old male with a C2 distal radius fracture; (b) Frontal and lateral radiographs of the left wrist joint at 2 days postoperatively showed a well-displaced fracture; (c) Frontal and lateral radiographs of the left wrist joint before removal of the external fixation device at 4 weeks postoperatively; (d) Frontal and lateral radiographs of the left wrist joint before removal of the small splint at 7 weeks postoperatively.

Evaluation criteria for efficacy

All cases were followed up for 12 to 36 months, with a mean follow-up of 23.6 months. Frontal and lateral radiographs of the patients’ wrist joints were taken at postoperative week 7 and month 12, respectively, to observe changes in wrist radiographic data. Patients were evaluated for joint function and activity of daily living using the Gartland-Werley and Quick DASH scores at postoperative week 7, month 6, and month 12, respectively. Additionally, patient satisfaction and complications were recorded. Wrist stiffness was specifically defined as an active range of motion (AROM) of the wrist (sum of dorsiflexion, palmar flexion, radial deviation, and ulnar deviation) less than 50% of the contralateral uninjured side, combined with patient-reported functional limitation during activities of daily living, as assessed by the treating surgeon during follow-up visits.

Radiographic data were entered into a computer, and Palmar tilt angle, Radial inclination angle, Ulnar variance, and Radial height were measured and recorded using ImageJ software.

At postoperative week 7, month 6, and month 12, patients were scored according to the Gartland-Werley Wrist Scoring Criteria in terms of residual deformity, subjective evaluation, objective evaluation, and complications, respectively. A full score of 21 points was given, with larger scores indicating poorer outcomes.²¹ The questionnaire has been translated into Chinese.

At postoperative week 7, month 6, and month 12, patients’ ability to perform activities of daily living was assessed using the Quick DASH score, a simplified version of the DASH (Disabilities of the Arm, Shoulder and Hand) score. The Quick DASH score is used to assess the level of upper extremity symptoms, function, and disability. It comprises 11 questions and has a total score of 100 points, with larger scores indicating poorer outcomes.²² The questionnaire has been translated into Chinese.

At postoperative week 7, prior to the removal of external fixation or small splints, a survey was conducted to assess satisfaction with external fixation or small splints in both groups. The survey was based on a 10-point scale, with 10 points indicating the most satisfied and 0 points indicating the least satisfied. The specific evaluation criteria were as follows: Scores of 1 to 5 indicated dissatisfaction, 6 to 8 indicated satisfaction, and 9 to 10 indicated very satisfaction.²³

Statistical treatment

Statistical analyses were performed using SPSS 26.0 software (IBM, Armonk, NY, USA), and measures conforming to normal distribution were expressed as mean ± standard deviation ( $\bar{x}$ ±s). The independent samples t-test was employed to contrast the measurement data, including the Gartland–Werley score, Quick DASH score, and age, between the two groups. The Pearson’s chi-square test was utilized to compare the count data, such as gender and treatment satisfaction, between the two groups. In these analyses, a p-value of less than 0.05 was considered statistically significant.

Results

As detailed in the Methods section, the following results are based on the Per-Protocol Set analysis of 174 patients (86 in the early mobilization group and 88 in the control group) who completed the full follow-up.

Radiographic data

There were no significant differences in the palmar tilt angle, radial inclination angle, ulnar variance, and radial height between the patients in the early mobilization group and the control group at postoperative week 7 (p = 0.66, p = 0.60, p = 0.34, and p = 0.29, respectively). At the follow-up at postoperative month 12, no significant differences were observed in palmar tilt angle, radial inclination angle, and radial height between the two groups (p = 0.72, p = 0.94, p = 0.59, respectively). However, there was a significant difference between the ulnar variance of 3.3 ± 1.7 mm and 2.7 ± 1.9 mm in the early mobilization group and the control group, respectively (p = 0.03) (Table 2).

Table 2.

Comparison of the radiographic data at 7 weeks and 12 months postoperatively in the early mobilization group and the control group.

	Early mobilization group	Control group	t value	p value
Radiographic data (7 weeks)
Palmar tilt angle (°)	1.68 ± 5.73	2.07 ± 5.63	0.45	0.66
Radial inclination angle (°)	21.52 ± 4.09	21.88 ± 4.83	0.53	0.60
Ulnar variance (mm)	1.7 ± 1.6	1.4 ± 1.9	0.97	0.34
Radial height (mm)	10.2 ± 2.3	10.6 ± 2.7	1.07	0.29
Radiographic data (12 months)
Palmar tilt angle (°)	2.88 ± 4.36	3.13 ± 5.27	0.34	0.73
Radial inclination angle (°)	20.57 ± 2.92	20.60 ± 2.81	0.08	0.94
Ulnar variance (mm)	3.3 ± 1.7	2.7 ± 1.9	2.21	0.03
Radial height (mm)	10.5 ± 2.1	10.7 ± 2.4	0.53	0.59

Joint function

The Gartland-Werley scores at postoperative week 7 in the early mobilization group and the control group were 6.53 ± 3.47 and 8.05 ± 4.48, respectively, with significant differences between the two groups (p = 0.01). There was no significant difference in Gartland-Werley scores between the early mobilization group and the control group at the postoperative months 6 and 12 (p = 0.38, p = 0.34, respectively) (Table 3).

Table 3.

Comparison of Gartland-Werley scores ( $\bar{x}$ ±s, point) at 7 weeks, 6 months and 12 months postoperatively in the early mobilization group and the control group.

	Early mobilization group	Control group	t value	p value
Gartland-Werley score (7 weeks)
Residual deformity	0.81 ± 0.52	0.74 ± 0.58	0.90	0.37
Subjective evaluation	2.08 ± 1.32	2.73 ± 1.76	2.73	0.01
Objective comment	2.86 ± 1.78	3.52 ± 1.99	2.31	0.02
Complication	0.78 ± 0.60	1.06 ± 0.73	2.73	0.01
Total	6.53 ± 3.47	8.05 ± 4.48	2.48	0.01
Gartland-Werley score (6 months)
Residual deformity	0.53 ± 0.50	0.45 ± 0.50	1.06	0.29
Subjective evaluation	1.17 ± 1.04	1.27 ± 1.00	0.63	0.53
Objective comment	1.58 ± 1.39	1.75 ± 1.20	0.86	0.39
Complication	0.49 ± 0.55	0.65 ± 0.57	1.88	0.06
Total	3.78 ± 2.73	4.13 ± 2.45	0.88	0.38
Gartland-Werley score (12 months)
Residual deformity	0.33 ± 0.47	0.38 ± 0.49	0.68	0.50
Subjective evaluation	1.20 ± 1.12	1.32 ± 1.05	0.74	0.46
Objective comment	1.20 ± 1.06	1.27 ± 1.25	0.43	0.67
Complication	0.42 ± 0.54	0.51 ± 0.59	1.22	0.22
Total	3.13 ± 2.28	3.48 ± 2.54	0.95	0.34

Upper limb function

The Quick DASH scores at postoperative week 7 in the early mobilization group and control group were 26.84 ± 14.11 and 32.36 ± 15.54, respectively, with a significant difference between the two groups (p = 0.02). However, there was no significant difference in Quick DASH scores between the early mobilization group and the control group at the postoperative months 6 and 12 (p = 0.60, p = 0.45, respectively) (Table 4).

Table 4.

Comparison of Quick DASH scores ( $\bar{x}$ ±s, point) at 7 weeks, 6 months and 12 months postoperatively in the early mobilization group and the control group.

	Early mobilization group	Control group	t value	p value
Quick DASH score (7 weeks)	26.84 ± 14.11	32.36 ± 15.54	2.46	0.02
Quick DASH score (6 months)	15.12 ± 11.08	16.05 ± 12.37	0.52	0.60
Quick DASH score (12 months)	11.86 ± 9.07	12.98 ± 10.18	0.76	0.45

Treatment satisfaction

The satisfaction rate of treatment at the postoperative week 7 in the early mobilization group and the control group was 90.70% and 67.05%, respectively, with a significant difference between the two groups (p < 0.001). A total of 86 patients in the early mobilization group, 30 and 48 patients reported being very satisfied and satisfied, respectively, and a total of 88 patients in the control group, 21 and 38 patients reported being very satisfied and satisfied, respectively (Table 5).

Table 5.

Comparison of satisfaction scores at 7 weeks postoperatively in the early mobilization group and the control group.

	Early mobilization group	Control group	χ² value	p value
Very satisfied	30	21
Satisfied	48	38
Not satisfied	8	29
Satisfaction rate (%)	90.70%	67.05%	14.53	<0.001

Complication

A total of 8 patients in the early mobilization group and 15 patients in the control group experienced one or more complications, with no significant difference between the two groups (p = 0.13). In the early mobilization group and the control group, there were 2 and 5 cases of pin site infection, 1 and 2 cases of fixation issues, 1 and 2 cases of traumatic arthritis, 2 and 4 cases of wrist stiffness, and 3 and 5 cases of hypertrophic scar, respectively. Furthermore, one case of nerve injury was observed in the control group, and one case of chronic pain syndrome was observed in the early mobilization group (Table 6).

Table 6.

Registered Complications in the early mobilization group and the control group.

	Early mobilization group (n = 86)	Control group(n = 88)	p value
Pin site infection	2	5	0.26
Fixation issues	1	2	0.57
Traumatic arthritis	1	2	0.57
Wrist stiffness	2	4	0.42
Hypertrophic scar	3	5	0.47
Nerve injury	0	1	0.32
Chronic pain syndrome	1	0	0.31
Overall complications	8	15	0.13

Discussion

C-type DRF is a relatively common occurrence in clinical practice, particularly among the geriatric population.^1,6 According to the AO/OTA classification system, C-type DRF is distinguished by comminution and instability, which renders it more challenging to treat than A-type and B-type DRF. Complications such as traumatic arthritis and wrist deformity may frequently persist following conservative treatment of C-type DRF. This is due to the impact of the fracture on the articular surfaces and the shortening of the distal radius.^24,25 Consequently, the majority of experts advocate for an aggressive surgical approach.

In terms of surgical options, both external fixation and plate fixation have been demonstrated to be efficacious. However, both surgical approaches possess inherent advantages and disadvantages. Plate fixation enables precise anatomical restoration of the fracture site and facilitates early wrist mobilization, thereby preventing wrist stiffness. Nevertheless, it has the disadvantage of necessitating reoperation to remove the internal fixation device, which not only increases surgical trauma and financial burden but also may affect the patient’s quality of life. In contrast, external fixation circumvents the necessity for a second surgical procedure. Furthermore, external fixation can be employed in the presence of poor soft tissue conditions, rendering this approach a preferred choice for surgical intervention within a relatively brief interval following the injury.^19,20 Once the fracture has reached a stable state, the external fixation device can be removed. However, it should be noted that this procedure is not without risk. Potential complications may include, but are not limited to, pin site infections and wrist stiffness (defined in our study as AROM <50% of the contralateral side with functional impairment).^26,27 Despite the fact that a considerable number of clinical studies have demonstrated that there is no significant difference in clinical outcomes between external fixation and plate fixation in the treatment of DRF at the 1-year postoperative follow-up,^20,27,28 the optimal time for the removal of external fixation devices remains a matter of contention. The majority of experts concur that the optimal time for the removal of external fixation devices is approximately 6 to 7 weeks after surgery.^20,29–31 With such a prolonged period of external fixation across the wrist joint for C-type DRF may result in a limitation of wrist motion in the early stages, which may consequently affect the early recovery of joint function.

To mitigate the early motion limitations imposed by prolonged external fixation, we implemented a protocol of early transition to controlled mobilization. After 3–4 weeks, once initial fracture stability was achieved, the rigid external fixator was replaced with a lightweight support system that provided moderate containment while allowing guided wrist movement. This approach balances the need for continued fracture protection with the benefits of early joint mobilization. It is important to note that relying solely on small splints is not an optimal approach for patients with C-type DRF. This is because this method has limited effectiveness in maintaining radial length and is not sufficiently stable for immobilization of comminuted fractures. In contrast, external fixation can provide more reliable stabilization of the fracture while maintaining radial length, thereby maximizing anatomic restoration of the distal radius. Consequently, for the treatment of C-type DRF, external fixation is the preferred method. At approximately three to 4 weeks post-surgery, the wrist swelling had largely subsided, and the pressure pain of the distal radius was significantly reduced or absent. Imaging and physical examination indicated that the fracture and surrounding soft tissues were gradually stabilizing (Figure 2(c)). In our clinical experience with adult patients, particularly the elderly, visible callus on X-ray is typically observed around the 6th week postoperatively, rather than at 3–4 weeks. Nevertheless, even in the absence of radiographically apparent callus, we consider the fracture sufficiently stabilized for transition to small splints if the following clinical and imaging criteria are met: the fracture fragments maintain their reduced position without displacement, soft tissue swelling has significantly subsided, and local tenderness is minimal or absent. These findings suggest that a fibrous union may have formed, providing adequate early stability. Our protocol of switching to small splints at this stage allows earlier wrist mobilization without increasing the risk of redisplacement, as confirmed by the absence of cases of loss of reduction during follow-up in the early mobilization group. At this stage, the external fixation device, which provided strong rigid force, was removed, and small splints were applied, which provided relatively weak elastic force. This transition maintains the stable state of the fracture and facilitates early wrist exercise.

Biomechanical studies have demonstrated that the small splint fixation system can generate axial traction force at the fracture site through transverse pressure applied by the splints and straps. Experimental models have shown a strong positive correlation (r = 0.9723, P < 0.001) between transverse pressure and the resulting axial traction force, which helps maintain fracture alignment.³² Furthermore, optimized splint designs, such as those utilizing topology optimization and 3D printing, can achieve significant weight reduction (over 40%) while maintaining sufficient stiffness, with maximum displacement under load well below clinically acceptable thresholds.³³ Finite element analyses comparing different splint materials (e.g., willow wood, paper-based, anatomical) have confirmed that well-designed anatomical splints distribute pressure more evenly across soft tissues, minimizing peak stress concentrations and reducing the risk of pressure sores, while effectively transmitting stabilizing forces to the underlying bone.³⁴ The design principle of using strategic padding (e.g., a single dorsal separating pad combined with a volar flat pad) has also been shown to provide effective fracture reduction force (“bone-separating force”) comparable to traditional two-pad methods, while significantly reducing pressure on volar arteries and soft tissues, thereby enhancing safety.³⁵

Patients in the early mobilization group started wrist exercises at 4 weeks postoperatively, with no cases of fracture redisplacement noted during follow-up. Consequently, at 7 weeks postoperatively, the Gartland-Werley score and Quick DASH score were significantly superior in the early mobilization group compared to the control group. The imaging results demonstrated stable fractures and blurred fracture lines at 7 weeks postoperatively (Figure 2(d)). However, as the patients in the control group also gradually started wrist exercises, so there was no significant difference in the scores at 6 and 12 months postoperatively.

At the 12-months follow-up, radiographic data indicated that the ulnar variance was greater in the early mobilization group than in the control group. This suggests that there was shortening of the radius, a phenomenon that we hypothesized might be related to the relatively weak force of fixation provided by the small splint compared with external fixation. However, despite the shortening of the radius, this did not affect wrist function.

It is worth noting that the small splint designed specifically for DRF in the forearm weighs only 95 g, and its lightweight design has significant advantages over external fixation devices that typically weigh more than 300 g. As supported by biomechanical evidence,^32–34 this light weight does not equate to a lack of mechanical support. The small size, light weight, and comfort of the small splint facilitate the effective improvement of the patient’s ability to perform daily activities while the forearm is immobilized after replacing the small splint. In addition, the use of small splints enhances the safety of the treatment by avoiding the problem of pin site infection that may be caused by external fixation devices. In our clinical practice, we have observed that the majority of our patients exhibit a positive emotional response to the conversion of their external fixation to small splints. This positive emotional response was reflected in the patients’ satisfaction rate at week 7 postoperatively. The results of this study indicate that the satisfaction rate of patients in the early mobilization group was significantly higher than that of the control group. In the current healthcare environment, the subjective feelings of patients are increasingly emphasized, and therefore, this protocol is important for the improvement of patient satisfaction rates during the treatment process.

The choice between conservative and surgical treatment for elderly patients over 60 years of age with fractures involving the articular surface of the distal radius remains widely debated.^36–39 In light of the rising life expectancy of humans and the growing demand of elderly patients for complete restoration of joint function and appearance, we have innovatively combined surgical treatment, exemplified by external fixation, with conservative treatment, exemplified by small splints. This comprehensive treatment has proven to be not only effective, but also improves patient comfort and satisfaction while the forearm is immobilized. In the future, we will continue to investigate the differences in efficacy between treating DRF patients with external fixation combined with small splints versus only small splints. We anticipate further substantiating the current findings and developing a secure and dependable treatment plan for elderly patients with complex DRF. This study employed a retrospective, non-randomized controlled trial design. All patients included in the study were from a single medical center, which may have introduced some bias into the results.

Conclusion

A structured protocol of 3–4 weeks of external fixation followed by early mobilization with a biomechanically effective lightweight support promotes earlier functional recovery and enhances patient satisfaction in elderly patients with C-type DRF, compared to prolonged rigid fixation. Although associated with a slight increase in ulnar variance, this did not translate into functional impairment.

Footnotes

Acknowledgements

We would like to express our profound gratitude to all those who have assisted us in the preparation of this paper.

Nan Fang

Shilin Yan

Zhigang Wang

Aofei Yang

Ethical approval

This study was approved by the Ethics Committee of Hubei Provincial Hospital of Traditional Chinese Medicine (Approval Number: HBZY2024-C114-01). All participants/patients (or their proxies/legal guardians) provided informed consent to participate in the study.

Author contributions

Aofei Yang: Designed the trials and wrote the draft. Nan Fang: Performed the trials and wrote the original draft. Zitong Wang and Zijian Wu: Performed and investigated the trials. Jiecheng Jiang and Shilin Yan: Analyzed and interpreted the data. Zhigang Wang: Contributed materials, analysis tools, and data.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the 2024 General Project of the Natural Science Foundation of Hubei Province (Grant No: 2024AFB977) and the Hubei Provincial Health Commission’s Youth Talent Program (Grant No: ZY2025Q036) for the years 2025-2026.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.*

References

Bilge

Dündar

Atılgan

, et al. The epidemiology of adult fractures according to the AO/OTA fracture classification. Ulus Travma Acil Cerrahi Derg 2022; 28: 209–216.

Luokkala

Laitinen

Hevonkorpi

, et al. Distal radius fractures in the elderly population. EFORT Open Rev 2020; 5: 361–370.

Sagerfors

Jakobsson

Thórdardóttir

, et al. Distal radius fractures in the superelderly: an observational study of 8486 cases from the Swedish fracture register. BMC Geriatr 2022; 22: 140.

Patel

Statuta

Ahmed

. Common fractures of the radius and ulna. Am Fam Physician 2021; 103: 345–354.

Holbrook

Doering

Mauck

. Common complications of distal radial fractures. Orthop Clin N Am 2021; 52: 241–250.

Corsino

Reeves

Sieg

. Distal radius fractures. StatPearls. 2024; 1–25.

Nogueira

Moratelli

Martins

MDS

, et al. Evaluation of distal forearm fractures using the AO 2018 classification. Acta Ortopédica Bras 2019; 27: 220–222.

Ruzicka

Kaiser

Schmidle

, et al. Conservative treatment of distal radial fractures. Operat Orthop Traumatol 2023; 35: 319–328.

Kitzen

Smith

Buckley

. AO C3 distal radial fracture - dorsal bridge plating versus ORIF. Injury 2021; 52: 3189–3191.

10.

Park

Sur

Kim

, et al. Simultaneous ipsilateral distal radius and radial head fractures: two case reports of radius bipolar fracture. Medicine (Baltim) 2021; 100: e24036.

11.

Garg

Mudgal

. Galeazzi injuries. Hand Clin 2020; 36: 455–462.

12.

Zengin

Ozcan

Aslan

, et al. Cast immobilization versus volar locking plate fixation of AO type C distal radial fractures in patients aged 60 years and older. Acta Orthop Traumatol Turcica 2019; 53: 15–18.

13.

Tian

, et al. Comparison of outcomes between nonsurgical and surgical treatment of distal radius fracture: a systematic review update and meta-analysis. Arch Orthop Trauma Surg 2020; 140: 1143–1153.

14.

Mulders

MAM

Walenkamp

MMJ

van Dieren

, et al. Volar plate fixation in adults with a displaced extra-articular distal radial fracture is cost-effective. J Bone Joint Surg Am 2020; 102: 609–616.

15.

Dabash

Potter

Pimentel

, et al. Radial plate fixation of distal radius fracture. Hand 2020; 15: 103–110.

16.

Boretto

Altube

Petrucelli

, et al. Dorsal plating for specific fracture pattern of the distal radius. J Hand Surg Asian Pac 2021; 26(26): 502–512.

17.

Rai

Tang

, et al. Fixation of delayed distal radial fracture involving metaphyseal diaphyseal junction in adolescents: a comparative study of crossed kirschner-wiring and non-bridging external fixator. BMC Muscoskelet Disord 2020; 21: 365.

18.

Gadegone

Lokhande

, et al. Distal radial fracture fixation in adults using intramedullary elastic wires augmented with either cast immobilisation or external fixation. Malays Orthop J 2021; 15: 36–44.

19.

Lee

Elfar

. External fixation versus open reduction with locked volar plating for geriatric distal radius fractures. Geriatr Orthop Surg Rehabil 2014; 5: 141–143.

20.

Zhang

Liu

Duan

, et al. Surgical options for distal radius fractures of type C in elderly patients over 65 years old: a comparison of external fixation with kirschner wires and volar locking plate. J Orthop Surg Res 2023; 18: 669.

21.

Gartland

Werley

. Evaluation of healed colles’ fractures. J Bone Joint Surg Am 1951; 33-A(4): 895–907.

22.

Beaton

Wright

Katz

, et al. Development of the QuickDASH: comparison of three item-reduction approaches. J Bone Joint Surg Am 2005; 87: 1038–1046.

23.

Lutz

Yeoh

MacDermid

, et al. Complications associated with operative versus nonsurgical treatment of distal radius fractures in patients aged 65 years and older. J Hand Surg Am 2014; 39: 1280–1286.

24.

Sagerfors

Jakobsson

Wretenberg

, et al. Treatment and outcome of AO/OTA type C distal radius fractures: 12 199 fractures from the Swedish fracture register. Acta Orthop Belg 2023; 89: 241–247.

25.

Grinčuk

Petryla

Masionis

, et al. Short-term results and complications of the operative treatment of the distal radius fracture AO2R3 C type, planned by using 3D-printed models. Prospective randomized control study. J Orthop Surg 2023; 31: 10225536231195127.

26.

Rundgren

Enocson

Järnbert-Pettersson

, et al. Surgical site infections after distal radius fracture surgery: a nation-wide cohort study of 31,807 adult patients. BMC Muscoskelet Disord 2020; 21: 845.

27.

Ludvigsen

Matre

Gudmundsdottir

, et al. Surgical treatment of distal radial fractures with external fixation versus volar locking plate: a multicenter randomized controlled trial. J Bone Joint Surg Am 2021; 103: 405–414.

28.

Maccagnano

Noia

Vicenti

, et al. Volar locking plate versus external fixation in distal radius fractures: a meta-analysis. Orthop Rev 2021; 13: 9147.

29.

Brogan

Richard

Ruch

, et al. Management of severely comminuted distal radius fractures. J Hand Surg Am 2015; 40: 1905–1914.

30.

Wang

Ilyas

. Dorsal bridge plating versus external fixation for distal radius fractures. J Wrist Surg 2020; 9: 177–184.

31.

Moses

Tejwani

. The role of external fixation in the management of upper extremity fractures. J Am Acad Orthop Surg 2023; 31: 860–870.

32.

Zhong

Liu

Dong

. Analysis of the axial stretching force of the small splint fiation system. Zhong Guo Gu Shang 2017; 30: 57–59.

33.

Yan

Ding

Kong

, et al. Lightweight splint design for individualized treatment of distal radius fracture. J Med Syst 2019; 43: 284.

34.

Hua

Wang

, et al. The biomechanical analysis of three-dimensional distal radius fracture model with different fixed splints. Technol Health Care 2018; 26: 329–341.

35.

. Comparison between two methods of fixation with small splints for forearm fracture. Zhonghua Wai Ke Za Zhi 1979; 17: 108–111.

36.

Michael

Nakhouzi

Kahhaleh

, et al. Volar locking plating compared to conservative treatment in distal radius fractures in elderly patients (>60 years old): a systematic review and meta-analysis of randomized controlled trials. J Hand Surg Glob Online 2023; 5: 589–594.

37.

Shen

Chen

Jupiter

, et al. Functional outcomes and complications after treatment of distal radius fracture in patients sixty years and over: a systematic review and network meta-analysis. Injury 2023; 54: 110767.

38.

Pedersen

Mortensen

Rölfing

, et al. A protocol for a single-center, single-blinded randomized-controlled trial investigating volar plating versus conservative treatment of unstable distal radius fractures in patients older than 65 years. BMC Muscoskelet Disord 2019; 20: 309.

39.

Thorninger

Wæver

Tjørnild

, et al. VOLCON: a randomized controlled trial investigating complications and functional outcome of volar plating vs casting of unstable distal radius fractures in patients older than 65 years. J Orthop Traumatol 2022; 23: 54.

Distal radius fractures: External fixation for 6–7 Weeks versus early mobilization following 3–4 Weeks of external fixation and light splintage

Abstract

Background

Methods

Results

Conclusion

Keywords

Introduction

Materials and methods

Patient selection

General information

Surgical technique

Postoperative rehabilitation

Evaluation criteria for efficacy

Statistical treatment

Results

Radiographic data

Joint function

Upper limb function

Treatment satisfaction

Complication

Discussion

Conclusion

Footnotes

Acknowledgements

Ethical approval

Author contributions

Funding

Declaration of conflicting interests

Data Availability Statement

References