Surgical Treatment of Distal Radius Fractures Using Minimally Invasive Plate Osteosynthesis or Open Reduction and Internal Fixation: A Five-Year Comparative Follow-Up Study

Abstract

Distal radius fractures (DRFs) constitute one of the most prevalent injuries in adults. This study compares the clinical and radiological outcomes of intra- and extra-articular DRFs treated with percutaneous Kirschner wires (PKW) or volar locking plates (VLP). Materials and Methods: A retrospective analysis was conducted on 42 patients (aged 18 to 85) treated between 2017 and 2019 with a minimum follow-up of five years. Outcomes were assessed using radiographic parameters and validated clinical scoring systems such as Disabilities of the Arm, Shoulder, and Hand (DASH), Patient-Rated Wrist Evaluation (PRWE), and Mayo Wrist Score (MAYO). Results: Clinical outcomes were better in the VLP group but not statistically significant (p > 0.05). For extra-articular fractures, DASH were 1.5 (VLP) vs. 6.4 (PKW) (p = 0.5007), PRWE were 1.3 (VLP) vs. 2.9 (PKW) (p = 0.4049), and MAYO were 95 (VLP) vs. 86.1 (PKW) (p = 0.2406). For intra-articular fractures, DASH were 6.6 (VLP) vs. 19.7 (PKW) (p = 0.0981), PRWE 12.9 (VLP) vs. 21.1 (PKW) (p = 0.3661), and MAYO 78.9 (VLP) vs. 72.2 (PKW) (p = 0.4503). Conclusions: PKW and VLP showed satisfactory long-term outcomes. VLP fixation allowed better short-term recovery and anatomical restoration, but long-term functional outcomes were comparable.

1. Introduction

Distal radius fractures (DRFs) are a common orthopedic injury in adults, characterized by a bimodal incidence: high-energy trauma in younger patients and low-energy mechanisms in elderly patients, particularly postmenopausal women with osteoporosis. Despite their rising prevalence, especially in the elderly, standardized management guidelines remain inconsistent [1,2]. Recent systematic reviews have compared the efficacy of volar locking plates (VLPs) and percutaneous Kirschner wire fixation (PKW), highlighting the advantages and limitations of both techniques [3].

An increase in DRF incidence, particularly in suburban populations, has been reported in some epidemiological studies, with variations in fracture patterns and treatment approaches [4].

In the United States, DRFs account for over 640,000 cases annually, representing 26–46% of fractures treated in primary care settings [5,6,7]. Epidemiologically, these fractures can be categorized into three age groups with different mechanisms of injury: children, young adults, and the elderly.

In young adults, DRFs occur less frequently—approximately 25% of fractures—and are primarily attributed to road traffic accidents and sports injuries [5,8]. In individuals over 50, the incidence increases significantly, particularly in women, due to osteoporotic changes [5,8,9]. The surgical management of DRFs primarily relies on percutaneous Kirschner wire fixation (PKW) or volar locking plate fixation (VLP), with numerous studies comparing functional and clinical outcomes between these two techniques [1,10,11,12,13,14,15].

The relationship between bone mineral density, patient-related outcomes, and fracture displacement has been further explored in recent studies, showing significant variations based on age and bone quality [16].

Treatment options for distal radius fractures range from conservative methods, such as bracing, to surgical techniques like external fixation, percutaneous Kirschner wire (PKW) fixation, and volar locking plate (VLP) fixation. The choice of treatment depends on the patient’s age, patient activity level, fracture type, and any associated injury. The main goal is to restore anatomical alignment and allow early mobilization to achieve the best functional recovery. Each technique has advantages and limitations. PKW fixation is a minimally invasive and cost-effective technique, offering shorter operative times and less soft tissue trauma [10]. However, it carries risks, including secondary displacement, radial shortening, implant mobilization (particularly in osteoporotic bone), and infection [12]. These complications can impact functional recovery, necessitating careful surgery planning and close clinical and radiographic monitoring.

Volar locking plate (VLP) fixation has become common in the last 20 years [2,17,18,19]. It provides better bone alignment and more stability and allows early movement, helping patients return to daily activities faster [2,18]. However, it may lead to complications such as loss of reduction [20] (0–9%), infection (0–6.6%), tendon issues (tenosynovitis, FPL, and EPL ruptures [21,22]), and complex regional pain syndrome (CRPS) (0–7%). Rare issues include nonunion, implant failure, and radial artery pseudoaneurysm [23].

In the literature, both treatments have demonstrated similar long-term outcomes, especially regarding functional recovery, despite some differences in early rehabilitation and complication profiles [11].

This study compares the long-term outcomes of intra-articular and extra-articular distal radius fractures (DRFs) treated with PKW or VLP fixation. Patients were assessed after an average of five years using clinical scores (DASH, PRWE, and MAYO Wrist Score) and radiographic evaluations to determine treatment effectiveness and functional recovery. While previous studies have compared PKW and VLP fixation, they mainly focused on short- and medium-term follow-ups with heterogeneous patient populations and varying evaluation criteria. Our study provides valuable long-term data by assessing clinical and radiological outcomes over a minimum period of five years. Despite its smaller cohort, its strength lies in the periodic evaluation of patients, ensuring continuous observation of functional and structural progress over time and offering a comprehensive perspective on long-term recovery.

2. Materials and Methods

2.1. Ethical Aspects

This study was conducted in accordance with the principles of the Declaration of Helsinki. As a retrospective observational study, formal ethical approval was not required. All patients provided written informed consent for the use of their clinical and radiographic data for research purposes. Data anonymity and confidentiality were ensured throughout this study.

2.2. Eligibility Criteria

This study included patients aged 18–85 years who sustained intra- or extra-articular distal radius fractures (DRFs) and underwent surgical treatment with either percutaneous Kirschner wires (PKW) or volar locking plates (VLP). Exclusion criteria comprised prior DRFs, neuromuscular or genetic disorders, malignancies, polytrauma, and alternative treatment methods. The relatively small sample size was due to strict inclusion criteria, requiring a minimum follow-up of five years and complete clinical radiographic documentation (preoperative, postoperative, and five-year radiographs; all DASH, PRWE, and MAYO scoring systems complete).

2.3. Description of the Experimental Stage

This retrospective analysis involved 42 patients treated between 2017 and 2019 at the Department of Orthopedics and Traumatology of the University of Rome, “Tor Vergata”. These institutions are tertiary referral centers specializing in orthopedic trauma care.

The PKW group underwent stabilization and immobilization with a short arm cast for approximately 30 days, followed by K-wire removal and physiotherapy to restore joint mobility and muscle strength. The VLP fixation was performed using a modified Henry approach, allowing for early rehabilitation initiation following suture removal. All patients were followed up periodically for five-year follow-up through radiographic assessments and clinical evaluations, including range of motion (ROM) measurements and scoring systems.

2.4. Scores

To assess functional outcomes, three validated scoring systems were employed:

• DASH (Disabilities of the Arm, Shoulder, and Hand): A self-administered 30-item questionnaire designed to measure upper limb disability and symptom severity. Each item assesses difficulty in performing various daily activities, with responses ranging from 1 (no difficulty) to 5 (unable to perform the activity). The final score is scaled from 0 to 100, where 0 represents no disability, and 100 indicates severe impairment. Lower scores reflect better functional ability and less disability;
• PRWE (Patient-Rated Wrist Evaluation): A condition-specific tool designed to assess pain and functional impairment in wrist injuries. It consists of 15 items divided into two subscales: pain (5 items) and function (10 items). Each item is scored on a scale from 0 (no pain or difficulty) to 10 (severe pain or difficulty), with a total score ranging from 0 to 100. Higher scores indicate greater pain and functional limitation;
• Mayo Wrist Score: A clinician-administered assessment tool used to evaluate overall wrist function. It includes four components: pain intensity, functional status (ability to work and perform daily activities), range of motion (ROM), and grip strength. Each component contributes to a total score ranging from 0 to 100, with higher scores indicating better wrist function and minimal impairment. This score is widely used to provide an objective measure of recovery following wrist fractures and surgical interventions (

  Table 1. Mayo Wrist Score.

  Category	Score	Findings
  (1) Pain intensity (25 points)	25	No pain
  	20	Mild, occasional
  	15	Moderate, tolerable
  	0	Severe to intolerable
  (2) Functional status (25 points)	25	Returned to regular employment
  	20	Restricted employment
  	15	Able to work, unemployed
  	0	Unable to work because of pain
  (3) Range of motion (25 points)	25	100% or 120° or more
  	15	75–100% or 90–120°
  	10	50–75% or 60–90°
  	5	25–50% or 30–60°
  	0	0–25% or 30° or less
  (4) Grip strength (25 points)	25	100%
  	15	75–100%
  	10	50–75%
  	5	25–50%
  	0	0–25%

  ).

2.5. Statistical Analysis

As this was a retrospective study, clinical scores were obtained from both existing medical records and standardized evaluations performed during follow-up visits. Patients lacking complete documentation or follow-up visits were excluded from the analysis.

Outcome measures were stratified by treatment modality and fracture type. Data were presented as mean values ± standard deviations and analyzed using a two-tailed Student’s t-test. Statistical significance was set at p < 0.05, with a 95% confidence interval.

2.6. Limitations and Bias

Some limitations should be considered when interpreting the results. First, the retrospective nature of this study introduces a risk of selection bias and limits the ability to control for confounding variables that may have influenced the clinical and radiographic outcomes. Additionally, the relatively small sample size (n = 42) and the wide age range of participants (18–85 years) may limit the statistical power to detect significant differences between treatment groups and could affect bone healing and rehabilitation response, potentially compromising the reliability of the results. Furthermore, outcome assessment was performed only at the final follow-up, without intermediate evaluations that could have provided a more detailed understanding of the clinical course during the first postoperative year.

3. Results

Patients were divided into four groups according to fracture type and treatment method (

Table 2. Division of patients and demographics. SD, standard deviation; PKW, percutaneous K. wire; VLP, volar locking plate.

Groups	Number of Patients	Mean Age (SD)	Men	Women
1. Extra-articular fracture treated with PKW	18	65 (9.59)	5	13
2. Intra-articular fracture treated with PKW	9	66.2 (8.18)	2	7
3. Extra-articular fracture treated with VLP	6	49.1 (11.81)	4	2
4. Intra-articular fracture treated with VLP	9	60.8 (12.18)	4	5

and

Table 3. Treatment technique and demographic of patients. SD, standard deviation; PKW, percutaneous K. wire; VLP, volar locking plate.

Treatment	Number of Patients	Mean Age (SD)	Men	Women
PKW	27	65.4 (9.17)	7	20
VLP	15	56.2 (13.33)	8	7

). Groups 1 and 2 included 27 patients treated with percutaneous Kirschner wires (PKW). Group 1 included 18 patients (mean age: 65 years) with extra-articular fractures, while Group 2 included 9 patients (mean age: 66.2 years) with intra-articular fractures. Groups 3 and 4 consisted of 15 patients treated with volar locking plates (VLP). Group 3 included six patients (mean age: 49.1 years) with extra-articular fractures, and Group 4 included nine patients (mean age: 60.8 years) with intra-articular fractures (Table 2).

At the final follow-up, both treatment groups demonstrated satisfactory clinical outcomes, with no statistically significant differences in functional scores. Patients treated with VLP fixation exhibited slightly better mean DASH, PRWE, and Mayo scores compared to those treated with PKW, particularly in intra-articular fractures. However, these differences did not reach statistical significance (p > 0.05), suggesting comparable long-term functional recovery between the two techniques.

For extra-articular fractures, patients treated with VLP fixation showed lower disability and pain scores compared to those treated with PKW. Although there was a trend toward improved functional outcomes in the VLP group, the differences did not reach statistical significance (Figure 1 and

Table 4. Functional outcome scores of extra-articular fractures. PKW, percutaneous K. wire; VLP, volar locking plate.

Extra-Articular Fractures	DASH (SD)	PRWE (SD)	MAYO (SD)
VLP	1.5 (0.8)	1.3 (0.6)	95 (4.5)
PKW	6.4 (2.1)	2.9 (1.5)	86.1 (6.2)
p value	0.5007	0.4069	0.2406

).

For intra-articular fractures, the VLP group exhibited better functional outcomes in all three scoring systems. However, the differences between the groups were not statistically significant, indicating that both techniques provided comparable long-term recovery (Figure 2 and

Table 5. Functional outcome scores of intra-articular fractures. PKW, percutaneous K. wire; VLP, volar locking plate.

Intra-Articular Fractures	DASH (SD)	PRWE (SD)	MAYO (SD)
VLP	6.6 (3.2)	12.9 (5.1)	78.9 (7.8)
PKW	19.7 (4.9)	21.1 (6.3)	72.2 (8.5)
p value	0.0981	0.3661	0.4503

).

Overall, satisfactory outcomes were observed in 88.1% of cases (37/42 patients) (Figure 3 and Figure 4), while 11.9% (5/42) exhibited some degree of residual impairment, predominantly among those with intra-articular fractures. Specifically, two patients treated with PKW and two with VLP for intra-articular fractures showed suboptimal recovery, highlighting the complexity of managing articular involvement. Additionally, one patient with an extra-articular fracture treated with PKW experienced unsatisfactory results.

Despite the higher mean functional scores observed in the VLP group, none of the differences between treatment methods reached statistical significance (p > 0.05) (Table 4 and Table 5). Radiographic evaluations confirmed stable fixation across all groups, with no evidence of hardware failure, secondary displacement, or malunion (Figure 5 and Figure 6). Furthermore, no cases of major complications, including complex regional pain syndrome (CRPS), tendon injuries, or nerve deficits, were reported during the follow-up period.

4. Discussion

Distal radius fractures (DRFs) represent a common clinical challenge, particularly in elderly patients with osteoporosis. Our study provides a five-year comparative analysis of two widely used surgical techniques: percutaneous Kirschner wire fixation (PKW) and volar locking plate fixation (VLP). The results indicate that both techniques yield satisfactory long-term functional outcomes, with no statistically significant differences in DASH, PRWE, or MAYO scores. However, VLP demonstrated advantages in early functional recovery and anatomical restoration, particularly for intra-articular fractures [15].

Complications associated with VLP fixation have been widely documented in the literature. One of the major concerns is the risk of flexor tendon injuries, particularly involving the FPL, which has been linked to volar plating techniques [21,22]. The potential wear of the FPL tendon due to implant positioning has been confirmed in cadaveric studies, highlighting the importance of screw placement and plate design in reducing these risks [22].

Another critical aspect is the stability of reduction following osteosynthesis with volar locking plates. Recent studies have demonstrated that epiphyseal screw positioning can significantly influence the risk of secondary displacement, affecting long-term outcomes [20]. While VLP offers better anatomical restoration and early functional recovery, complications such as implant-related discomfort, tendon irritation, and plate prominence have been reported [24]. These findings further support the need for individualized treatment planning, considering fracture type, bone quality, and patient activity level.

Our findings align with previous randomized controlled trials (RCTs) and meta-analyses. Recent studies have emphasized the importance of treatment selection based on fracture type and patient characteristics [25]. Specifically, VLP fixation has been associated with improved early functional outcomes and greater anatomical restoration compared to PKW, particularly in osteoporotic patients [26]. However, as demonstrated in the CROSSFIRE study, in elderly patients, closed reduction and percutaneous fixation may offer similar long-term results, minimizing surgical morbidity [27].

Furthermore, functional recovery outcomes are also influenced by fracture classification. Patiño et al. [28] found that volar plating provides better stabilization in complex fractures, supporting our findings of improved early rehabilitation in VLP-treated patients.

Costa et al. reported no significant differences in long-term functional outcomes between PKW and VLP at five years, despite initial advantages in wrist function for VLP in the early postoperative period [11]. Similarly, Karantana et al. found improved functional scores at six weeks postoperatively in VLP-treated patients, but this difference diminished at later follow-ups [29]. Meta-analyses by Chaudhry et al. [13], Franceschi et al. [10], and Tariq et al. [30] corroborate these findings, highlighting that while VLP offers superior early recovery, long-term outcomes remain comparable.

A meta-analysis by Youlden et al. further corroborates these findings, comparing volar locking plating and percutaneous Kirschner wires in an adult population. Their study emphasized that while VLP offers superior early functional recovery and stability, long-term outcomes remain comparable between the two techniques, reinforcing the notion that both methods are viable treatment options depending on patient-specific factors [31].

Despite these similarities, some studies suggest that VLP may provide better grip strength and radiographic alignment. Brennan et al. reported superior volar tilt and radial height maintenance in VLP-treated patients [32], while Ghosh et al. observed a lower loss of reduction rate in this group [33]. Additionally, Testa et al. [34] highlighted that periarticular fractures in elderly patients treated with VLP demonstrated better functional recovery and anatomical realignment. However, these advantages did not consistently translate into superior long-term functional outcomes, reinforcing our findings that both techniques are viable options depending on patient-specific factors.

The comparable long-term results suggest that treatment choice should be individualized. VLP appears preferable for complex intra-articular fractures requiring stable fixation and early mobilization, while PKW remains a viable option for extra-articular fractures, particularly in osteoporotic patients or those with higher surgical risk. Additionally, PKW offers advantages such as reduced cost, shorter surgical time, and less soft tissue disruption, albeit at the expense of potential secondary displacement [10,23,24].

Despite the relatively small sample size (n = 42), this study provides valuable insight due to several strengths. The five-year follow-up is among the longest reported in similar comparative studies, and the absence of patient loss ensures data completeness and reliability. Additionally, the stratification of patients based on fracture type and treatment modality allows for a more detailed assessment of outcomes. While the retrospective nature of this study introduces potential selection bias and limits the control of confounding variables, the findings align with the existing literature, reinforcing the notion that treatment decisions should be tailored to individual patient characteristics rather than assuming the superiority of one technique over the other.

This is important because the literature shows that differences in clinical outcomes are greater in the first few months and tend to decrease over time [35,36,37,38]. The evaluation of the three scores system was reported only at the final follow-up, which may have influenced the statistical significance of the results and the complication rate for the two procedures. In fact, no complications were reported in our series of patients. Prospective randomized studies with larger sample sizes and a more structured follow-up are needed to confirm these findings and further investigate the differences between the two treatment approaches.

Nevertheless, this study’s strength consists of the complete evaluation of all enrolled patients and the stratification of these patients into subgroups according to the location, type of fracture, and type of treatment. This detailed approach enhances the robustness of the long-term comparative data.

Future Perspectives

Future prospects in the treatment of distal radius fractures are strongly focused on treatment personalization and clinical research. The adoption of individualized therapeutic algorithms, based on the specific characteristics of the patient and the type of fracture, will enable the optimization of clinical outcomes by tailoring the treatment to each patient’s unique needs. This personalized approach could reduce complications and enhance functional recovery. At the same time, the importance of randomized controlled clinical trials is crucial for comparing the effectiveness of various surgical and conservative techniques, contributing to the development of evidence-based protocols. These studies, with larger sample sizes and structured follow-up, will provide a solid foundation for increasingly targeted and scientifically validated management of distal radius fractures.

5. Conclusions

In conclusion, our findings align with the existing literature, as no significant differences were observed between (VLPs) and (K-wires) in medium- and long-term functional outcomes, including range of motion, grip strength, and patient-reported outcomes, at a 5-year follow-up in patients aged 18–85 years of both sexes. However, VLPs demonstrated superior anatomical restoration, particularly in maintaining volar tilt and radial height, and provided enhanced fracture stability. This contributed to faster recovery of wrist functionality, shorter immobilization times, and earlier return to work, especially in cases of complex or intra-articular fractures. In contrast, K-wires remain a valuable option for simple extra-articular fractures or in patients with comorbidities where a less invasive approach is preferred. Consequently, we recommend that the choice of treatment be individualized, taking into account the type and complexity of the fracture, associated soft tissue injuries, bone quality (e.g., osteoporotic versus non-osteoporotic fractures), patient activity level, and overall health status to optimize outcomes.