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Journal of Hand Surgery

(European Volume)
Percutaneous pinning versus volar locking 0(0) 1–10
! The Author(s) 2017
plate internal fixation for unstable distal Reprints and permissions:
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radius fractures: a meta-analysis DOI: 10.1177/1753193417735810
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Fei Peng, Yuan-xiang Liu and Zhen-yu Wan

Abstract
This meta-analysis compared outcomes between percutaneous pinning/wiring and open reduction internal
fixation (ORIF) with locking plates for treatment of unstable distal radius fractures. Medline, Cochrane,
EMBASE, and Google Scholar were searched through December 30, 2015. Twenty randomised controlled
trials (RCTs) and non-randomised two-arm studies were included. Outcomes included scores of
Disabilities of the Arms, Shoulders and Hands (DASH), visual analogue scale (VAS) pain, and patient rated
wrist evaluation (PRWE) score, as well as range of motion (ROM) and complication incidence. ORIF/plating
was associated with lower DASH scores but longer procedure time, while there was no difference between
the two methods with respect to VAS pain score and PRWE score. The overall incidence of complications,
including complex regional pain syndrome, was higher with pinning/wiring, though the incidence of carpal
tunnel syndrome and nerve defects was not different. Supination and grip strength were better with ORIF.
Radiographically, ulnar variation was greater with pinning/wiring. These results suggest that ORIF/plating is
the preferred method of managing unstable distal radius fractures.

Level of evidence: II

Keywords
Distal, external fixation, fracture, K-wire, locking plate, internal fixation, meta-analysis, ORIF, radius

Date received: 13th June 2016; accepted: 15th September 2017

(ORIF) with a volar locking plate (Ruch and McQueen,

Introduction
Fractures of the distal radius represent one of the
most common fractures seen by orthopaedic sur-
geons (Chung et al., 2006; Ruch and McQueen,
2010; Singer et al., 1998). These fractures are most
common in postmenopausal women, resulting from
osteoporosis, with a lifetime risk of sustaining a
distal radius fracture of 15% for women and 2% for
men (van Staa et al., 2001; Ruch and McQueen, 2010).
Fractures are primarily the result of high energy
trauma in young adults and from a simple fall in
the elderly (Ruch and McQueen, 2010). Despite their
frequent occurrence, the best choice for treating
unstable distal radial fractures is controversial.
While distal radius fractures may be treated with
casting if the bones are aligned, displacement may
require some form of reduction and fixation to
achieve an adequate outcome (Ruch and McQueen,
2010). The two most common methods of fixation
are external fixation using pins and/or Kirschner
wires (K-wire), and open reduction internal fixation
2010). K-wire fixation is mostly successful, but per-
cutaneous K-wires are not load bearing, do not pro-
tect against radial shortening, and have been
associated with loss of reduction, stiffness of the fin-
gers, sensory nerve disturbances, and pin track
infection (Kreder et al., 2005). ORIF with a locking
plate offers advantages over K-wire fixation including
greater stability, earlier mobilisation of the hand, and
return to normal activities; however, it is a more
invasive procedure with associated greater risk
(Karantana et al., 2013; Phadnis et al., 2012; Tubeuf
et al., 2015). Although various studies have compared
the two methods and examined various outcomes
Department of Orthopedics, Renmin Hospital of Wuhan University,
Wuhan, China
Corresponding author:
Fei Peng, Department of Orthopedics, Renmin Hospital of Wuhan
University, No. 99 Zhangzhidong Road, Wuchang District, Wuhan
430060, China.
Email: popfly_pf@hotmail.com
2 Journal of Hand Surgery (Eur) 0(0)
(Costa et al., 2014; Goehre et al., 2014; Hollevoet
et al., 2011; Jubel et al., 2005; Karantana et al.,
2013; Maire et al., 2013; Marcheix et al., 2010;
McFadyen et al., 2011; Oshige et al., 2007; Rozental
et al., 2009; Saddiki et al., 2012; Zhao et al., 2012),
it remains unclear which is the better treatment .
Prior meta-analyses have not definitively shown
that one procedure has clear advantages over the
other (Meier et al., 2012; Wei et al., 2012; Zong
et al., 2015).
Thus, the purpose of this study was to perform a
meta-analysis to compare functional and radio-
graphic outcomes and complications between percu-
taneous pinning/wiring and ORIF using a locking
plate for treating unstable distal radius fractures.
Methods
Literature search strategy, study selection,
and data extraction
This systematic review and meta-analysis was con-
ducted in accordance with PRISMA guidelines
(Liberati et al., 2009). Medline, Cochrane, EMBASE,
and Google Scholar databases were searched up to
December 30, 2015 using combinations of the follow-
ing keywords: percutaneous pin, pinning, K-wire,
Kirschner, locking plate, plate osteosynthesis,
radius, forearm fracture. Reference lists of relevant
studies were manually searched to identify potential
articles of interest. There was no language restric-
tion in the database searches. Searches were con-
ducted by two independent reviewers, YL and ZW, and
a third reviewer, FP, was consulted for resolutions of
any disagreements. All reviewers were orthopaedic
hand surgeons.
We included randomised controlled trials (RCTs),
non-randomised two-arm studies, and retrospective
studies comparing percutaneous pinning/wiring
versus ORIF with volar locking plates for unstable
distal radius fractures. Inclusion also required that
the studies reported data of at least one outcome of
interest (as described below). No length of follow-up
time was specified. One-arm studies, letters, com-
ments, editorials, case reports, and proceedings
were excluded.
The following information was extracted from stu-
dies that met the inclusion criteria: the name of the
first author, year of publication, study design and
patient selection criteria, number of patients in
each treatment group, patient age and sex, fracture
type, surgeon experience, intervention, outcomes,
and follow-up time. Data were extracted by two
reviewers, and disagreements were resolved by con-
sultation with a third reviewer.
Quality assessment
The methodological quality of randomised studies
was assessed with two reviewers using the risk-of-
bias assessment tool outlined in the Cochrane
Handbook for Systematic Reviews of Interventions
(version 5.1.0) (Higgins, 2011). Briefly, six domains
were evaluated: random sequence generation, allo-
cation concealment, blinding of patients and person-
nel, blinding of outcome assessment, incomplete
outcome data, and selective reporting risk. Non-ran-
domised studies were assessed by two independent
reviewers using the Newcastle-Ottawa scale (NOS),
which is a validated tool for evaluating non-rando-
mised studies for three criteria: patient selection,
comparability of study groups, and outcome
assessment.
Outcome measures and data analysis
Outcome measures examined in the meta-analysis
were Disabilities of the Arms, Shoulders and Hands
(DASH) score, visual analogue scale (VAS) pain score,
patient rated wrist evaluation (PRWE) score, proced-
ure time, range of motion (ROM), grip strength, radio-
graphic assessment parameters (radial length, ulnar
variance, volar tilt, radial inclination) and total com-
plication incidence. Complications included non-
union, wound infection (superficial or deep), nerve
injuries, carpal tunnel syndrome, complex regional
pain syndrome, tendon complications (rupture or
inflammation), loss of reduction, and reoperation.
Outcomes were compared between the two
groups. Odds ratios (ORs) were calculated for dichot-
omous outcomes, and standard difference in means
(SDM) were calculated for continuous outcomes
along with 95% confidence intervals (CIs) in the pin-
ning/wiring group compared with the ORIF/plating
group. A 2-based test of homogeneity was per-
formed, and the inconsistency index (I2) and
Cochran Q statistics were determined. If the I2 stat-
istic was > 50% or the Cochran Q value of p
was < 0.01, significant heterogeneity was considered
to be present and a random-effects model of analysis
was used. Otherwise, a fixed-effects model was
employed.
Some argue that since clinical and methodological
diversity always occur in a meta-analysis, statistical
heterogeneity is inevitable (Higgins et al., 2003).
Thus, testing for heterogeneity is irrelevant to the
choice of analysis because heterogeneity will
always exist, whether or not it can be detected
using a statistical test. To this end, methods have
been developed for quantifying inconsistency across
studies that move the focus away from testing
Peng et al.
whether heterogeneity is present to assessing its
impact on the meta-analysis. A useful statistic for
quantifying inconsistency is: I2 ¼ (Q-df/Q)  100%,
where Q is the chi-square statistic and df is its
degrees of freedom (Higgins and Thompson, 2002;
Higgins et al., 2003). This describes the percentage
of the variability in effect estimates that is due to
heterogeneity rather than sampling error (chance).
However, thresholds for the interpretation of I2 can
be misleading since the importance of inconsistency
depends on several factors. A rough guide to inter-
pretation is as follows: 0% to 40%: might not be
important; 30% to 60%: may represent moderate het-
erogeneity; 50% to 90%: may represent substantial
heterogeneity; 75% to 100%: considerable hetero-
geneity. Thus, most studies use a cutoff of 50% to
determine which method of analysis is used (i.e.,
random-effects or fixed-effects).
Pooled effects were calculated, and a two-sided p
value < 0.05 was considered to indicate statistical
significance. Subgroup analysis was also performed
by study design (RCTs versus non-randomised stu-
dies). Since RCTs and non-randomised trials repre-
sent different levels in evidence-based medicine, we
used subgroup analysis to address the clinical het-
erogeneity between these two types of studies.
Sensitivity analysis was carried out using the
leave-one-out approach. A sensitivity analysis is
used to clarify whether the findings are consistent
and robust; consistent results provide stronger evi-
dence of an effect (Higgins, 2011). Publication bias
analysis was not performed if there were < 10 stu-
dies, as  10 studies are needed to detect funnel plot
asymmetry (Sterne et al., 2011). The absence of pub-
lication bias was indicated by the data points forming
a symmetric funnel-shaped distribution and one-
tailed significance level p > 0.05 by Egger’s test.
Publication bias occurs when the publication of stu-
dies depends on the nature and direction of the
results; thus, results of published studies may be
systematically different from those of unpublished
studies (Dickersin 1990). In general, studies with sta-
tistically-significant or positive results are more
likely to be published than those with non-significant
or negative results (Song et al., 2010). A funnel plot is
used to estimate the risk of publication bias in meta-
analyses (Light and Pillemer, 1984). When the true
treatment effect equals zero, the biased selection of
studies with significant results will produce a funnel
plot with an empty area around zero. Many statistical
methods (e.g., Egger’s test) have been developed to
test funnel-plot asymmetry, as statistical methods
may provide a more objective and accurate assess-
ment of funnel-plot asymmetry than subjective visual
assessment. The performance of tests for funnel-
3
plot asymmetry is particularly poor when the
number of studies is small, and heterogeneity is
large in a meta-analysis. For this reason, it is rec-
ommended that tests for funnel-plot asymmetry
should not be used in meta-analyses that include
fewer than 10 studies (Sterne et al., 2011).
All analyses were performed using
Comprehensive Meta-Analysis statistical software,
version 2.0 (Biostat, Englewood, NJ, USA).
Results
Literature search and study characteristics
A flow diagram of study selection is shown in Figure 1.
A total of 118 articles were identified in the database
searches, and 58 remained after duplicates were
removed. Screening of the 58 articles by title and
abstract excluded 24. The full texts of the remaining
34 articles were reviewed, and 14 were excluded, the
reasons for which are shown in Figure 1. Thus, 20
articles were included in the meta-analysis (Aita
et al., 2014; Bahari-Kashani et al., 2013; Costa et al.,
2014; Dzaja et al., 2013; Egol et al., 2008; Goehre
et al., 2014; Gradl et al., 2013; Grewal et al., 2011;
Hollevoet et al., 2011; Jeudy et al., 2012; Karantana
et al., 2013; Kumbaraci et al., 2014; Lee et al., 2012;
Loisel et al., 2015; Maire et al., 2013; Marcheix et al.,
2010; McFadyen et al., 2011; Rozental et al., 2009;
Tronci et al., 2013; Williksen et al., 2013).
The basic characteristics of the 20 studies are pre-
sented in Supplementary Table 1, and outcomes are
summarised in Supplementary Tables 2 and 3. The 20
studies included 1,805 patients; 14 were RCTs, and
six were non-randomised studies. The total number
of patients ranged from 16 to 230 in the percutaneous
pinning/wiring groups and from 16 to 231 in the ORIF/
plating groups. The average patient age ranged from
18 to 75 years, and the percentage of male patients
ranged from 6% to 70% (Supplementary Table 1).
Meta-analysis
Dash score. Thirteen studies reported DASH scores,
and a fixed-effect model of analysis was used as there
was no evidence of significant heterogeneity
(I2 ¼ 39.68%. Q ¼ 18.236, p ¼ 0.076) (Figure 2(a)). The
overall analysis revealed ORIF/plating was associated
with significantly better DASH scores than percutan-
eous pinning/wiring (pooled SDM ¼ 0.237; 95% CI:
0.128 to 0.346; p < 0.001, Figure 2(a)). Subgroup ana-
lysis of the two non-randomised studies indicated that
ORIF/plating was associated with significantly better
DASH scores than percutaneous pinning/wiring
(pooled SDM ¼ 0.419; 95% CI: 0.066 to 0.771;
4 Journal of Hand Surgery (Eur) 0(0)
Figure 1. Flow diagram of study selection.
p ¼ 0.020). Analysis of the 10 RCTs also indicated
better DASH scores with percutaneous pinning/
wiring (pooled SDM ¼ 0.218; 95% CI: 0.104 to 0.333;
p < 0.001).
VAS pain score and PRWE. Four studies reported
VAS pain data and PRWE data. Fixed-effect models
of analysis were used as no evidence of heterogeneity
was observed for either measure (VAS: I2 ¼ 26.65%
Q ¼ 4.090, p ¼ 0.252; PRWE: I2 ¼ 45.10%, Q ¼ 5.464,
p ¼ 0.141) (Figure 2(b) and (c)). Overall analysis
revealed no significant difference of VAS pain score
or PRWE score between percutaneous pinning/wiring
and ORIF/plating (Figure 2(b), (c)). No significant dif-
ference in either measure was observed in subgroup
analysis of RCTs and non-randomised studies.
Procedure time. Eleven studies reported procedure
time, and a random-effects model of analysis was
used as significant heterogeneity was present
(I2 ¼ 96.68%, Q ¼ 301.26, p < 0.001) (Figure 2(d)).
Overall analysis revealed ORIF/plating was asso-
ciated with a longer procedure time than percutan-
eous pinning/wiring (pooled SDM ¼ 1.863, 95% CI:
2.683 to 1.043, p < 0.001) (Figure 2(d)). Analysis
of the three non-randomised studies also indicated
that ORIF/plating had a longer procedure time
(pooled SDM ¼ 1.871; 95% CI: 3.632 to 0.109;
p ¼ 0.037), as did analysis of the eight RCTs (pooled
SDM ¼ 1.861; 95% CI, 2.787 to 0.935; p < 0.001).
Complication incidence. Nine studies reported com-
plication data, and a fixed-effect model of analysis
was used, as no significant heterogeneity was pre-
sent (I2 ¼ 20.22%, Q ¼ 10.03, p ¼ 0.263) (Figure 2(e)).
Overall analysis revealed a significant difference in
the total number of complications between the per-
cutaneous pinning/wiring and ORIF/plating groups
(pooled OR ¼ 1.989; 95% CI: 1.354 to 2.923;
p < 0.001) (Figure 2(e)). Subgroup analysis of three
non-randomised studies indicated percutaneous pin-
ning/wiring had a significantly higher incidence of
Peng et al.
Figure 2. Forest plots showing results of meta-analysis for (a) DASH score, (b) VAS pain score, (c) PRWE, (d) procedural
time, and (e) total complication rates for patients treated with EF pinning/wiring versus ORIF locking plates.
complications than ORIF/plating (pooled OR ¼ 3.615;
95% CI: 1.344 to 9.723; p ¼ 0.011). An analysis of six
RCTs indicated there was significant difference in the
incidence of complication between the two groups
(pooled OR ¼ 1.788; 95% CI: 1.178 to 2.716;
p ¼ 0.006) .
Wound infection, carpal tunnel syndrome, nerve def-
icits, and complex regional pain syndrome. Overall
analysis revealed that patients treated with percu-
taneous pinning/wiring had a significantly higher
incidence of superficial wound infections (pooled
OR ¼ 5.28; 95% CI: 2.49 to 11.20; p < 0.001) and com-
plex regional pain syndrome (pooled OR ¼ 2.49; 95%
CI: 1.21 to 5.13; p ¼ 0.013) than those managed with
ORIF/plating (Supplementary Table 4). No difference
was found in the incidence of carpal tunnel syndrome
or nerve deficits between the two groups.
Range of motion and radiographic outcomes. Results
of the meta-analysis of ROM and radiographic out-
comes are shown in Supplementary Table 5. Overall
analysis indicated range of supination was signifi-
cantly greater in patients treated with ORIF/plating
5
(pooled SDM ¼ 0.274; 95% CI: 0.520 to 0.027;
p ¼ 0.029). Subgroup analysis of non-randomised
studies indicated that ORIF/plating was associated
with greater grip strength (pooled SDM ¼ 0.468;
95% CI: 0.855 to 0.082; p ¼ 0.018), but subgroup
analysis of RCTs indicated no difference in these
measures between the two groups.
The overall analysis revealed that percutaneous
pinning/wiring had significantly greater ulnar vari-
ance compared to ORIF plating (pooled
SDM ¼ 0.520; 95% CI: 0.223 to 0.818; p ¼ 0.001)
(Supplementary Table 5). In addition, subgroup ana-
lysis of non-randomised studies and RCTs indicated
percutaneous pinning/wiring was associated with
greater ulnar variance (pooled SDM ¼ 0.797;
p ¼ 0.014 for subgroup of non-randomised studies;
pooled SDM ¼ 0.443; p ¼ 0.010 for subgroup of RCTs).
Sensitivity analysis and publication bias
Sensitivity analyses were performed using the leave-
one-out approach (Supplementary Table 6). The dir-
ection and magnitude of pooled estimates for DASH
score, VAS pain score, PRWE score, procedure time,
6 Journal of Hand Surgery (Eur) 0(0)
Figure 2. Continued.
and total complications did not vary with studies
removed in turn, indicating that the meta-
analyses had good reliability.
No evidence of publication bias was found with
respect to DASH score (Figure 3(a)) and procedure
time (Figure 3(b)).
Quality assessment
Results of the quality assessment of the included
studies are shown in Figure 4 and Supplementary
Table 1. Performance and detection biases were pre-
sent in the RCTs as there was no blinding, but there
was little selection, attrition, or reporting bias. The
NOS scores for the non-RCTs ranged from 7–9 out of
9, indicating overall high quality.
Discussion
The overall results indicated that ORIF/plating was
associated with significantly better DASH scores,
whereas there was no difference between the two
methods with respect to VAS pain scores and PRWE
scores. The procedure time for ORIF/plating was
longer. The overall incidence of complications,
including that of complex regional pain syndrome,
was higher with pinning/wiring, though the inci-
dences of carpal tunnel syndrome and nerve defects
Peng et al.
Figure 3. Funnel plots for (a) DASH score, (b) procedural time, and (c) total complication rate.
were not different. Supination and grip strength were
better with ORIF, and radiographically, ulnar vari-
ation was greater with pinning/wiring.
Several prior meta-analyses and literature
reviews have attempted to determine the most
appropriate treatment for distal radius fractures. A
review by Meier et al. (2012) compared percutaneous
K-wires with volar locking plates. The results of the
studies varied remarkably, leading the authors to
conclude that both methods are suitable treatments
and that while locking plates may lead to an earlier
functional recovery, this advantage disappears in
long-term follow-up. A 2012 meta-analysis by Wei
et al. (2012) compared external and internal fixation
by pooling the data from 12 trials with a total of 1,011
patients (491 fractures were treated with external
fixation and 520 with ORIF. ORIF was associated
with better DASH scores, recovery of forearm supin-
ation, and restoration of volar tilt. Conversely, exter-
nal fixation was associated with significantly better
grip strength, and subgroup analyses of randomised
7
studies showed external fixation resulted in better
wrist flexion. A meta-analysis by Zong et al. (2015)
comparing volar locking plates with percutaneous
K-wire fixation for dorsally displaced distal radius
fractures and found that ORIF with a volar locking
plate resulted in statistically better DASH scores
and reduced incidence of total postoperative compli-
cations, specifically superficial infections. Better grip
strengths and ranges of wrist flexion and supination
at 6 months postoperatively were also seen
with ORIF.
We did not distinguish between younger and older
patients in this analysis, and treatment outcomes
with a particular method may vary with patient age.
Leung et al. (2008) compared external pin fixation
with plate fixation for intra-articular distal radius
fractures in a group of patients with an average age
of 42, none of whom were over 60. At 24 months of
follow-up, plate fixation resulted in better outcomes
based on the Gartland and Werley point system
(p ¼ 0.04) and the radiographic arthritis grading
8 Journal of Hand Surgery (Eur) 0(0)

Figure 4. Risk of bias summary, and overall assessment of risk of bias.

system (p ¼ 0.01). Differences were greatest in
patients with AO C2 fracture. The multi-centre
ORCHID trial (Open Reduction and Volar Locking
Plate Fixation Versus Closed Reduction and Cast
Immobilisation) randomised 185 patients 65 years of
age or older with AO type C distal radial fractures to
ORIF or closed reposition and casting. At 1 year after
treatment, there was no significant difference in
Short Form (SF)-36 or EuroQol (EQ)-5D score.
While DASH scores favoured ORIF, the differences
were considered clinically unimportant (Bartl et al.,
2014). Thirty-seven study participants (41%) who
were primarily allocated to cast treatment under-
went secondary surgical treatment due to loss of
reduction within 2 weeks (Bartl et al., 2014).
Phadnis et al. (2012) compared fixed-angle plate
fixation with K-wire fixation of distal radius AO A2, A3,
and C1 fractures in patients aged 65 years and older.
Functional results after 1 year were similar, though
plate fixation patients were able to resume normal
activities 4 weeks earlier. Diaz-Garcia et al. (2011)
performed a systematic review of outcomes and
complications of treating unstable distal radius frac-
tures in the elderly with volar locking plates, non-
bridging external fixation, bridging external fixation,
percutaneous K-wire fixation, and cast immobilisa-
tion. Wrist arc of motion, grip strength, and DASH
scores were significantly different between the
groups; however, the authors suggested that the dif-
ferences were not clinically meaningful. Casting
Peng et al.
resulted in the worst radiographic outcomes, which
may not be meaningful because full return of func-
tion may not be as important in older patients com-
pared to younger patients.
Cost analysis is important when comparing differ-
ent procedures to achieve the same goal; however,
an analysis of cost-effectiveness was beyond the
scope of our study. The direct costs of ORIF are gen-
erally higher. Indirect costs include radiographs,
follow-up visits, additional surgery, and length of
rehabilitation. These costs need to be evaluated
when examining the cost-effectiveness of different
treatment methods. This is certainly a complicated
issue; however, in a study performed in the United
Kingdom, Karatana et al. (2013) reported that from a
National Health Service perspective there was no evi-
dence to support the cost-effectiveness of either
locking plates or external fixation for the operative
treatment of dorsally displaced radial fractures.
Because of the socioeconomic impact of healthcare
costs, further study of the cost-effectiveness of dif-
ferent treatment methods for displaced radial frac-
tures is warranted.
While this meta-analysis included more studies
than prior studies, there were limitations. There
was heterogeneity with respect to the fracture
types studied. Most included studies focused on
patients with AO type A and C fractures, but several
studies (Costa et al., 2014; Egol et al., 2008; Loisel
et al., 2015; Maire et al., 2013) also included patients
with type B fractures, and we did not perform a sub-
group analysis based on fracture type. There was
also heterogeneity in the procedures and materials
used as well as the methods of external fixation.
We did not distinguish between intra- and extra-
articular fractures, and the experience level of the
surgeons performing the procedures varied.
Follow-up duration was not examined, and the bene-
fits of one method over the other may diminish over
time. Lastly, the situation is different in young and
elderly patients. We attempted to perform a sub-
group analysis based on age, but the studies did
not stratify patients by age (i.e., whether they were
young or elderly). Thus, the data were not available to
perform this analysis. However, in all studies except
one, the mean age of the patients was over 40 years.
Further studies focusing on young and elderly
patients are warranted.
In conclusion, the current updated meta-analysis
examining the treatment of unstable distal radius
fractures indicates that ORIF/plating is associated
with better functional outcomes based on DASH
score as well as a lower incidence of complications,
including superficial wound infections and complex
regional pain syndrome. These results suggest that
9
ORIF/plating is the preferred method of managing
unstable distal radius fractures.
Declaration of conflicting interests The authors
declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the
research, authorship, and/or publication of this article.
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