European Journal of Cardiovascular Medicine

Distal radius fractures (DRFs) are among the most common orthopaedic injuries in adults, representing approximately one-sixth of all fractures treated in clinical settings [1, 2]. These fractures typically occur at the metaphyseal region of the distal radius and are frequently caused by falls onto an outstretched hand. The incidence of DRFs follows a bimodal distribution, with younger patients often sustaining these injuries due to high-energy trauma, such as motor vehicle collisions or sports-related impacts, while older individuals, particularly postmenopausal women with osteoporosis, are more susceptible to low-energy mechanisms, such as falls from a standing height [3]. The management of DRFs remains a subject of ongoing debate, with treatment options broadly categorized into conservative (non-surgical) and surgical approaches [4]. The primary goal of treatment is to restore optimal wrist function while maintaining the anatomical alignment of the radiocarpal and distal radioulnar joints [5]. Inadequate reduction or stabilization can lead to complications such as malunion, chronic pain, joint stiffness, and reduced grip strength, ultimately affecting the patient’s functional independence and quality of life. The choice between conservative and surgical intervention depends on several patient-specific factors, including age, bone quality, fracture displacement, hand dominance, occupational demands, and comorbidities. Non-displaced or minimally displaced fractures are often managed non-surgically through closed reduction and cast immobilization. However, conservative treatment may be less effective in elderly patients with osteoporotic bone, as they are at higher risk of secondary displacement and poorer functional recovery [6]. In contrast, surgical intervention, particularly open reduction and internal fixation (ORIF) with volar locking plates, has become increasingly favored due to its ability to achieve anatomical restoration, provide stable fixation, and allow early mobilization. Despite the growing trend toward surgical management, there remains a lack of high-quality comparative studies evaluating long-term functional outcomes, particularly hand grip strength, between patients treated conservatively and those undergoing ORIF. Hand grip strength is a critical objective measure of upper extremity function and serves as a reliable indicator of recovery following DRF treatment. It is influenced by multiple factors, including hand dominance, age, gender, nutritional status, and overall muscle conditioning [7].

Due to its high inter-rater reliability and strong correlation with functional hand use, grip strength assessment provides valuable insight into the effectiveness of different treatment modalities. The shift in treatment preferences toward surgical fixation highlights the need for robust comparative data to guide clinical decision-making [8]. While previous studies have examined radiographic outcomes and range of motion following DRF management, few have systematically compared grip strength recovery between patients treated with closed reduction and casting versus ORIF. Given that grip strength is essential for daily activities and occupational performance, its evaluation offers a practical means of assessing functional outcomes between treatment groups.

This study aims to address this gap by comparing hand grip strength in patients with DRFs treated via closed reduction and casting versus ORIF. By analyzing post-treatment grip strength ratios (non-dominant/dominant hand), this research seeks to determine whether surgical fixation provides a functional advantage over conservative management, thereby contributing to evidence-based treatment strategies. The findings may have significant implications for rehabilitation protocols, patient counseling, and the optimization of treatment approaches for DRFs across different patient populations. Thus, DRFs are a major clinical concern in orthopedics, with treatment strategies varying based on fracture characteristics and patient demographics. While conservative management remains an option for select cases, surgical fixation is increasingly preferred for its potential to improve anatomical and functional outcomes. This study will provide valuable data on post-treatment grip strength, helping clinicians make informed decisions and optimize patient recovery [9]. The aim of the present study was to compare the hand grip strength in patients with distal radius fractures treated by closed reduction and casting to those treated by open reduction and internal fixation.

This is a randomized clinical trial, which was conducted on 50 patients with distal radial fracture plus radius coronal shift, who came for the treatment in the Department of Orthopaedics, Indira Gandhi Institute of Medical Sciences, Patna, Bihar (India).

Inclusion criteria:

• Patient Age: 18-65 years.
• Frykman type I–VIII fractures, which were impossible to reduce or retain in an acceptable position in a cast after closed reduction.
• Injury less than 10 days previously.
• Incongruence in RC-or DRU-joint and/or axial compression > 2 mm, and/or dorsal angulation > 20°.
• The patient had received oral and written information and signed an informed consent.

Exclusion criteria:

• Previous ipsilateral fracture.
• Volarly displaced fracture.
• Fracture in the contralateral side, or other fractures in need of treatment
• Open fracture.
• Ongoing radiotherapy or chemotherapy.
• Metabolic disease affecting the bone.
• Medication affecting the bone.
• Dementia, psychiatric disorder, or alcohol abuse.

The patients were categorized into two groups based on the treatment received:

• Group I: consisted of patients who were treated conservatively (n=25).
• Group II: consisted of patients who were treated surgically (n=25).

In the group I patients, immobilisation of the hand, with a below-elbow Colles cast, was done for a period of 6-8 weeks. In group II patients, the method of fixation included Open Reduction Internal Fixation by Locking Compression Plate, External Fixation, and K-WIRE. Multiple bone pieces did not allow fixation with plates and screws, therefore in such cases, an external fixator with or without additional wires was used to secure the fracture.

After the surgery, a splint was placed for 2 weeks until the first follow-up visit, at which the splint was removed and exchanged with a removable wrist splint for 4 weeks. Assessment of Hand grip strength was done using a hand grip dynamometer. The patient was asked to hold the grip dynamometer with the elbow flexed to 90◦ and the radioulnar joint in its neutral position. The dynamometer was set at one of five specified settings (1, 1.5, 2, 2.5, and 3 inches). The patient was asked to squeeze the dynamometer’s handle with maximum force (without holding their breath) at every setting. Adequate recovery time was given between bouts. The values were recorded, and the test was repeated on the opposite hand.

The obtained data is expressed in terms of Mean and standard deviation. A p-value less than 0.05 was considered significant in this study for the analysis. The findings were tabulated and analyzed statistically by using the GraphPad Prism version 9 software.

We compared the functional outcomes between patients with distal radius fractures treated by closed reduction with cast immobilization (Group I) versus open reduction and internal fixation (ORIF, Group II), assessing both disabilities of the arm, shoulder, and hand (DASH) scores and grip strength. For functional disability measured by DASH scores, Group I (cast immobilization) showed a mean score of 24.13 ± 8.17 while Group II (ORIF) had 29.87 ± 11.88, with no statistically significant difference between the groups (F = 0.712, p = 0.485). In terms of grip strength recovery, Group I demonstrated a mean strength of 58.13 ± 14.23 pounds compared to Group II's 62.35 ± 10.43 pounds, revealing a statistically significant difference favoring the ORIF group (F = 4.342, p = 0.041). These results indicate that while both treatment approaches resulted in similar self-reported functional outcomes, ORIF provided better recovery of grip strength, suggesting potential advantages in restoring hand function following distal radius fractures.

Table 1: Showing the comparison of the mean DASH score of study participants

Table 2: Showing the comparison of mean grip strength (pounds) of study participants

The management of distal radius fractures presents a complex clinical challenge where orthopaedic surgeons must carefully weigh the benefits and risks of various treatment modalities. These common injuries, representing approximately one-sixth of all fractures seen in emergency departments, exhibit a wide spectrum of clinical presentations and outcomes. The complication rate associated with distal radius fractures has been reported to vary dramatically from 6% to 80% in different studies [10], with these adverse outcomes stemming either from the inherent nature of the injury itself or as consequences of the chosen treatment approach. This substantial variability in complication rates underscores the critical need for thorough investigation into the most effective treatment strategies to optimize patient recovery and functional outcomes. In the current investigation, we conducted a detailed comparative analysis of hand grip strength recovery in patients with distal radius fractures treated through two fundamentally different approaches: closed reduction with cast immobilization versus open reduction and internal fixation.

The demographic characteristics of our study population revealed important considerations for interpreting the results. Age and gender have been consistently identified in the literature as significant factors influencing functional outcomes following treatment for distal radius fractures [10]. In our cohort, the mean age of participants in the closed reduction group was 44.56 ± 9.45 years compared to 38.11 ± 9.76 years in the surgical group, a difference that did not reach statistical significance. Similarly, the gender distribution between groups was well-balanced. This demographic equivalence between treatment groups strengthens the validity of our comparative analysis by minimizing potential confounding variables that could otherwise influence functional outcomes. The age range of our participants is particularly noteworthy as it represents a population that is typically highly active both professionally and recreationally, for whom optimal recovery of hand function is particularly crucial.

Hand grip strength emerged as a central focus of our investigation due to its well-established role as a comprehensive indicator of upper extremity function [11]. This measurement represents the maximum isometric strength of the hand and forearm musculature and has been shown to correlate strongly with overall upper limb functionality and capacity for activities of daily living [12]. Beyond its value as a musculoskeletal assessment tool, grip strength has gained recognition as an important general health indicator, with numerous studies demonstrating that reduced grip strength serves as a predictor for various adverse health outcomes, including disability, mobility limitations, increased fall risk, and even mortality [13]. In our study, the quantitative assessment of grip strength revealed statistically significant differences between treatment approaches, with the open reduction and internal fixation group demonstrating superior recovery (62.35 ± 10.43 pounds) compared to the closed reduction group (58.13 ± 14.23 pounds). This finding carries substantial clinical implications, suggesting that surgical intervention may facilitate better restoration of functional capacity following distal radius fractures.

The superior grip strength outcomes observed in the surgically treated group align with several previous investigations in this field. The work of Arora and colleagues [14] produced similar findings, reporting significantly better hand grip strength in patients managed operatively compared to those treated non-operatively. These researchers emphasized the importance of anatomical restoration and stable fixation in achieving optimal functional recovery. Similarly, Karagiannopoulos and associates [15] documented better grip strength outcomes in surgically treated distal radius fracture patients, attributing these results to the biomechanical advantages of internal fixation. Their study highlighted how rigid stabilization allows for earlier and more aggressive rehabilitation, potentially preventing the muscle atrophy and joint stiffness that can develop during prolonged immobilization. Saving and co-authors [16] expanded on these observations by demonstrating improvements in both grip strength and DASH scores (Disabilities of the Arm, Shoulder, and Hand) following volar plating compared to non-operative management, suggesting that surgical intervention may provide comprehensive benefits across multiple domains of upper extremity function.

However, the literature presents some conflicting perspectives that warrant careful consideration. Hidayat and colleagues [17] reported no significant difference in grip strength outcomes between operatively and non-operatively treated groups in their 2020 study, raising important questions about the universal superiority of surgical approaches. Their findings suggest that certain fracture patterns or patient populations may achieve comparable functional outcomes with either treatment modality. Similarly, Egol and associates [18] presented evidence that diminished grip strength in conservatively managed patients did not necessarily correlate with poorer long-term functional recovery, indicating that the human body possesses remarkable adaptive capacity. These divergent findings underscore the complexity of distal radius fracture management and emphasize the need for individualized treatment decision-making that considers multiple factors beyond simple strength measurements.

The biomechanical advantages of open reduction and internal fixation likely contribute substantially to the superior grip strength outcomes observed in our surgical group. Internal fixation techniques, particularly volar locking plate systems, provide several theoretical benefits, including more accurate anatomical reduction, rigid stabilization of fracture fragments, and preservation of fracture alignment during the healing process. These technical advantages translate clinically into earlier mobilization opportunities, reduced immobilization-related complications, and more predictable fracture healing. The importance of anatomical restoration cannot be overstated, as even minor articular incongruities or malalignments have been associated with accelerated joint degeneration and compromised long-term function. Furthermore, the stability afforded by internal fixation may create a more favorable environment for bone healing by minimizing micromotion at the fracture site while still allowing controlled loading through the extremity.

In contrast, closed reduction and cast immobilization, while less invasive, present several potential limitations that may explain the relatively inferior grip strength outcomes in our study. Traditional casting techniques often fail to maintain reduction in unstable fracture patterns, particularly those with metaphyseal comminution or articular involvement. The inability to directly visualize and address intra-articular components represents another significant limitation of non-operative management. Additionally, prolonged immobilization in a cast may lead to muscle atrophy, joint stiffness, and delayed rehabilitation initiation, all of which could negatively impact ultimate strength recovery. However, it is crucial to recognize that casting remains an appropriate and effective treatment for many stable, minimally displaced fractures, particularly in lower-demand patients where the risks of surgery may outweigh the potential benefits.

The rehabilitation process following each treatment approach likely plays a substantial role in the observed functional outcomes. Surgical fixation typically permits earlier initiation of active motion exercises, often beginning within the first postoperative week for stable internal fixation constructs. This early mobilization may help prevent the development of adhesions, maintain joint lubrication, and preserve muscle strength. In contrast, cast immobilization generally requires 4-6 weeks of continuous immobilization before progressive mobilization can begin, potentially allowing stiffness and weakness to develop during this critical healing period. The difference in rehabilitation timelines between treatment approaches may significantly influence the rate and completeness of functional recovery, particularly in working-age populations where rapid return to vocational and avocational activities is often a priority.

Patient-specific factors must be carefully considered when interpreting these results and applying them to clinical practice. The optimal treatment approach for any given distal radius fracture depends on a complex interplay of fracture characteristics, patient demographics, functional requirements, and comorbidities. Younger, active patients with high functional demands may derive particular benefit from surgical intervention given its potential for superior strength recovery and earlier functional return. Conversely, elderly patients with osteoporotic bone or significant medical comorbidities may achieve satisfactory outcomes with non-operative management despite potentially lower ultimate grip strength measurements. The concept of "acceptable reduction" varies substantially across patient populations, with lower-demand individuals often tolerating greater degrees of residual deformity without functional compromise.

The economic implications of treatment selection represent another important consideration that extends beyond the purely clinical outcomes. Surgical management typically involves higher initial costs related to implants, operating room time, and hospital resources. However, these upfront expenses may be offset by potential long-term savings if surgical treatment reduces the need for secondary procedures, decreases rehabilitation duration, or enables earlier return to productivity. Comprehensive cost-effectiveness analyses that incorporate direct medical costs, indirect societal costs, and quality-adjusted life years would provide a valuable additional perspective on the comparative value of these treatment approaches.

Our study findings must be interpreted in the context of certain methodological limitations. The sample size, while adequate for detecting statistically significant differences in our primary outcome measure, may have been insufficient to identify more subtle differences in secondary outcomes or subgroup analyses. The follow-up duration of one year provides valuable intermediate-term data, but cannot speak to the very long-term consequences of treatment selection, particularly regarding the development of post-traumatic arthritis or chronic pain syndromes.

Future research directions should aim to address these limitations while expanding our understanding of distal radius fracture management. Larger, multicenter randomized controlled trials with extended follow-up periods would provide more definitive evidence regarding the comparative effectiveness of these treatment approaches. Investigations incorporating advanced imaging techniques could elucidate the relationship between radiographic parameters and functional outcomes with greater precision. Research exploring optimized rehabilitation protocols tailored to specific treatment modalities and patient characteristics would help maximize functional recovery regardless of treatment selection. Additionally, studies examining patient-reported outcomes and quality-of-life measures would complement the biomechanical data provided by grip strength testing.

This study found that while surgically treated DRF patients showed significantly better grip strength recovery, both treatment approaches resulted in similar DASH scores and range of motion outcomes. These findings suggest that while surgical management may offer advantages in restoring hand strength, conservative treatment remains a viable option for maintaining overall function and mobility in DRF patients. The choice between treatments should be individualized based on patient characteristics and functional requirements.

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