Achieving a major milestone in Nordic orthopaedic trauma research, Nordic NITEP study group successfully conducted and published a large randomized multicenter trial addressing a long-standing and clinically contentious question in the management of distal radius fractures in older patients. With this study, we provide high-quality evidence that directly informs clinical decision-making and is likely to change established treatment pathways both nationally and internationally.
If an acceptable reduction of a distal radius fracture (wrist fracture) in patients aged over 65 years cannot be achieved in the emergency department, we found that early surgical treatment with a volar locking plate (VLP) may result in slightly better outcomes than nonoperative treatment. However, the mean difference between treatment groups remained below the minimal clinically important difference (MCID). If fracture alignment deteriorates during cast treatment, surgical intervention does not appear to provide additional benefit compared with continued cast immobilization. These findings call into question the need for early radiographic follow-up during the initial treatment phase.
We conducted a randomized multicenter trial comparing cast immobilization with surgical treatment using a volar locking plate. Patients whose fracture alignment did not meet acceptable criteria after closed reduction were randomized to either surgical treatment or cast treatment. Patients whose fracture was initially reduced to an acceptable position but subsequently lost alignment during the first 10 days of follow-up were also randomized to surgery or continued cast treatment.
Our primary outcome was the Patient-Rated Wrist Evaluation (PRWE) score at 12 months after fracture. Secondary outcomes included other functional outcome measures, complications, pain catastrophizing, quality of life, and the rate of reoperations. The primary analytical method was a linear mixed-effects model.
We recruited a total of 291 patients (mean age 73 years [SD 5.8]; 258 women and 33 men). Among patients whose fractures could not be reduced to an acceptable position, the mean treatment effect at 12 months favored surgery by −9.6 PRWE points (95% CI −17.4 to −1.7). This difference persisted throughout the first year of follow-up and was of similar magnitude in patients younger and older than 75 years. On average, however, the difference was smaller than the prespecified MCID (11 points). In patients whose fracture alignment deteriorated during the first 10 days of follow-up, the mean treatment effect on PRWE at 12 months was −6.2 points (95% CI −15.4 to 3.0).
Based on these findings, we conclude that the treatment strategy for distal radius fractures in older patients should be determined immediately after closed reduction using shared decision-making in discussion with the patient. Subsequent radiographic monitoring of fracture alignment does not appear to provide additional benefit in terms of expected wrist function. Our results support a simplification of current care pathways and are likely to influence clinical practice in the management of distal radius fractures both in Finland and internationally.
Hevonkorpi et al. 2025: Nonoperative treatment versus volar locking plating for distal radius fracture in patients aged 65 years or older (DRIFT trial): A randomized controlled trial