Distal radius fractures are the most common type of all fractures seen in the emergency department and constitute 10% to 25% of all extremity fractures [1, 2]. The incidence of distal radius fractures continues to rise as the population in industrialised countries grows in line with an increase in age and life expectancies [3, 4]. The occurrence of distal radius fractures peaks within two different age groups: high energy trauma, typically in males aged 5–24 years, or low-energy injuries commonly seen in the elderly female population aged 65 years and older .
The treatment of distal radius fractures has developed greatly over recent years with a move towards treating these fractures by means of internal fixation. Although closed reduction and casting remain viable options for some non-displaced simple fractures of the distal radius, the role of ORIF continues to grow due to its ability to more reliably restore wrist anatomy, minimize immobilization and establish acceptable clinical outcomes . Numerous methods of surgical stabilisation exist including: manipulation with Kirschner wires (k-wires), external fixators, dorsal and volar plating and fragment specific fixation. All have been found to be successful in maintaining correction of the reduced fracture however volar plating has more recently become the favourable choice for managing distal radius fractures especially in more complex fracture patterns and/or osteoporotic bone [6–8]. The advent of variable angle volar plating systems has also allowed cases with increasing comminution and displacement, poor bone quality, and dorsally angulated fractures, to be fixed with less tendon irritation and the reduced need for hardware removal [8, 9]. In addition, volar plating allows restoration of anatomy, stable fixation, reduced periods of immobilisation and earlier return to function [6, 8]. As the popularity of volar plating has increased so has the number and type of volar plating systems available to orthopaedic surgeons. Differences range from the plate design (i.e. shape and contour), material, type, locking screw mechanism and number of screws used. The general benefits of variable angle plating systems have been reported to include :
Flexible deployment with respect to variations in radial size;
Accommodation of proximal/distal variation in volar fracture lines;
Accommodation of medial and lateral variation in fracture lines;
Adaptation of screw direction to specific fracture fragments.
A recent literature review conducted by Gehrmann et al. on distal radius fracture management in the elderly, found that patients with higher demands benefit from fracture stabilisation using locking volar plates . Volar plating with fixed-angle screws may also be particularly suitable for elderly patients whose fractures take longer to heal or are more susceptible to pin-site infection.
Additionally, newer features of volar plates, such as locking and variable angle mechanisms, have been thought to further reduce complication rates and improve effectiveness in patients of all ages . This remains controversial however, as a number of complications including loss of fixation, tendon irritation or rupture, median nerve complications and distal radial ulnar joint dysfunction, have been reported in the literature [10, 11]. Various factors, such as plate and screw type, have been found to contribute to this complication rate, which highlights the importance of investigation into clinical and radiological outcomes of surgery for this patient population.
Comparison of complications between dorsal and volar plates has been examined previously with results indicating a higher rate of association between volar plates and neuropathic complications but less tendon irritation or ruptures than dorsal plates . A study by Soong et al. also found that very few complications were recorded in their cohort of distal radius fractures fixed with volar plates, compared with dorsal plates .
A retrospective study of 115 patients with comminuted intra-articular distal radius fractures was performed by Richards et al. who compared radiographic and clinical outcomes of patients treated with external fixation to those treated with volar plate internal fixation . They reported fewer complications, better range of movement, pain and functional scores in the ORIF group.
A randomised clinical trial of 53 patients comparing external fixation and ORIF (either dorsal or volar plates) by Grewal and colleagues found that ORIF had significantly lower Patient Rated Wrist Evaluation (PRWE) scores across all time points (3, 6, 12 months) with better outcomes observed in the volar plating group .
Park et al. investigated the clinical outcomes of a consecutive cohort of 20 patients undergoing ORIF of their distal radius fractures using the Medartis Aptus Volar Plate up to a one year period . They found that all fractures healed in every case by 12 weeks post-operation with no loss of reduction in 19 cases (of 20 patients). Range of movement, grip strength and Disability of the Arm, Shoulder and Hand (DASH) scores were all within acceptable ranges.
Previous studies have investigated the clinical and radiological outcomes of volar plating systems in cohort series designs [9, 13, 14]. Osada et al. found in their series of 49 fractures in 49 patients fixed with volar plates, good radiological results, good to excellent Gartland and Werley scores, low DASH scores, a high degree of patient satisfaction and no record of complications except plate removal . A total of three plates were removed between six and 10 months postoperatively. Two plates were removed due to patient request and the other was removed because the distal locking pins appeared to be intra-articular on the computed tomography scan . Sanchez-Crespo retrospectively reviewed 145 patients (fixed with either a Medartis Aptus Volar 2.5 mm Plate or Synthes 2.4mmLCP distal radius plate) and analysed results of 95 of these patients . They found good mean functional scores using the PRWE (mean 13; range 0–64) however 8% of patients presented with a complication (e.g. chronic pain, malunion, tendon tears, carpal tunnel syndrome, or requiring hardware removal).
Titanium and stainless steel volar plating systems for distal radius fractures are both readily available and in common use in orthopaedic surgery. Titanium implants have been reported to have benefits including reduced implant stiffness, increased biocompatibility and diminished stress shielding . However tenosynovitis and extensor tendon ruptures have been reported in the use of low profile titanium plates used for dorsal fixation of distal radius fractures . Conversely, stainless steel plates have been thought to have less tendon irritation and adhesions when used in wrist surgery .
Recently, Souer et al. specifically investigated the clinical and radiological outcomes comparing 2.4 mm titanium and 3.5 mm stainless steel volar plates and found improved range of movement in the group that received the 2.4 mm titanium plate at 12 and 24 months post-surgery . However, patients in the 3.5 mm stainless steel volar plate group had better radiological outcomes at all time points. Along with the obvious limitations in the study design (retrospective review of a prospective cohort), sample size (n = 62), and high loss to follow-up, the results could be attributed to either the plate thickness or material type. To date, no randomized trials are known to exist comparing material type (i.e. stainless steel versus titianium) of volar plates.
The research question for this study is: Do patients who have their distal radius fractures internally fixated with a titanium plate have the same outcomes as patients who have their distal radius fractures internally fixated with a stainless steel plate?