K-Wires Offer No Advantage Over Plaster Casts in Improving Wrist Fracture Outcomes

Pavankumar Kamat

January 20, 2022

Fixation using metal Kirschner wires (K-wires) offers no advantage over traditional moulded plaster casts in improving wrist function and pain in patients with distal radius fractures. These findings were reported by a randomised controlled trial (RCT) recently published in  The BMJ .

Surgery and casting for wrist fractures have their own pros and cons. While surgical fixation provides reliable functional outcomes, it also carries certain risks and is costly. On the other hand, casting is safer and economical but may not provide the same functional outcomes as surgery.

Study Details

In the DRAFFT2 RCT conducted across 36 hospitals in the UK, 500 individuals (mean age 60.1 years; 83% female) with a dorsally displaced distal radius fracture were randomly assigned to receive either manipulation and moulded plaster cast (n=255) or manipulation and surgical fixation with K-wires (n=245). The primary outcome was pain and wrist function at 12 months assessed using the Patient Rated Wrist Evaluation (PRWE) score.

The study reported that 395 (79%) patients completed the follow-up. Both groups demonstrated improvement in their PRWE score at 12 months from injury, but were unable to achieve their pre-injury level of wrist function. At 12 months, there was no significant difference in the PRWE score between the cast group and the K-wire group (adjusted mean difference -0.34; 95% CI -4.33 to 3.66; P=0.87). Similarly, there were no significant differences between the groups at 3 and 6 months.

Both groups also demonstrated improvements in health related quality of life assessed using the EQ-5D-5L index from injury until 12 months, but there was no significant difference between the groups at 12 months (adjusted mean difference -0.03; 95% CI -0.07 to 0.02; P=0.026). Similar findings were observed with the EQ-5D visual analogue scale.

Thirty-three (13%) patients in the cast group required surgical fixation for loss of fracture reduction in the first 6 weeks, whereas only 1 (0.4%) patient in the K-wire group required revision surgery (OR 0.02, 95% CI 0.001 to 0.10; P<0.001).

The trial had some limitations, the most important being the absence of treatment blinding for both treating physicians and patients.

The authors concluded: "A cast is an acceptable first-line treatment following manipulation of a dorsally displaced fracture of the distal radius. Cast treatment avoids the expense and risks of surgical fixation for 7 out of 8 patients. However, careful follow-up is needed as 1 in 8 patients treated with a cast required subsequent surgical intervention as the fracture reduction could not be maintained.”

The trial was funded by the UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme and was supported by NIHR Oxford Biomedical Research Centre. The authors declare support from the UK NIHR HTA Programme for the submitted work.

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