The Wrist and Radius Injury Surgical Trial (WRIST): 12-month outcomes from a multicenter international randomized clinical trial.

BACKGROUND: Optimal treatment for distal radius fractures (DRFs) in older adults remains uncertain. No randomized trials comparing the most frequently used treatments in this population have been conducted. Surgical treatment rates vary widely, though the sustained benefits of surgery are uncertain. METHODS: The Wrist and Radius Injury Surgical Trial (WRIST), randomized, multicenter trial, enrolled 304 adults age 60 years and older with isolated, unstable DRFs at 24 institutions. Patients who wanted surgery (n=187) were randomized to internal fixation with volar plate (VLPS), external fixation (EFP), or percutaneous pinning; patients who preferred conservative management (n=117) received casting. The primary outcome was the 12-month Michigan Hand Outcomes Questionnaire (MHQ) Summary score. Secondary outcomes included MHQ domain scores and radiographic parameters. RESULTS: At 12 months, there were no differences by treatment in primary or the majority of secondary outcomes. Twelve-month MHQ Summary scores differed between VLPS and EFP by 3 points (97.5% CL: -6.0, 11.5) and between VLPS and pinning by -0.14(-9.2,8.9). However, at 6 weeks, mean MHQ Summary score for VLPS was greater than EFP by 19(p<0.001), pinning by 11(p<0.001) and casting by 7(p=0.03). VLPS participants demonstrated significantly better radiologic alignment throughout the follow-up period, though there was no relationship between any outcome and radiographic alignment. Malunion was experienced by 48% of casting participants. CONCLUSIONS: Recovery was fastest for VLPS participants and slowest for EFP participants according to most measures, but by 12 months there were no meaningful differences in outcomes. Casting participants experienced satisfactory results despite loss of radiologic alignment.