Distal radius fractures (DRFs) are one of the most frequent fractures seen in orthopedic practice and account for a significant proportion of pain, dysfunction, and temporary or permanent disability.[1] These fractures occur following falls onto an outstretched hand, road traffic accidents, sports injuries, and other forms of trauma.[2] Distal radius fractures represent about 18% of the fractures in older people and are an important clinical and socioeconomic problem.[3] The impact of the outcome is not limited to healing of a fracture, as a limited range of wrist movement, loss of grip strength, and persistent pain can affect activities of daily living, work, and personal independence.[4, 5]

Treatment for distal radius fractures will vary depending on fracture configuration, displacement, and involvement of the articulation, stability, bone quality, age, and functional demands.[6] Closed reduction with cast immobilization continues to be an accepted therapy, especially for fractures that can be reduced and maintained in an acceptable position.[7]  However, maintaining fracture reduction can be challenging in unstable or substantially displaced fractures, potentially resulting in secondary displacement, malunion, restricted wrist movement, and impaired functional recovery.[8] The use of open reduction and internal fixation with a volar locking plate, on the other hand, allows for the direct reduction of the fracture and stable fixation, allowing for early mobilization and rehabilitation.[9]

There is a difference in functional recovery between volar locking plate fixation and closed reduction and casting, which has been shown with evidence over time. A systematic review and meta-analysis, which included 12 randomized controlled trials and 1,368 patients, found that volar locking plate fixation provided superior Disabilities of the Arm, Shoulder and Hand (DASH) scores at 3 months, but there were no consistent long-term benefits in range of motion, grip strength, quality of life, or reoperation rates.[10]

In the last few years, studies in Pakistan have shown good functional outcomes after volar plating, and local comparative studies have compared the operative and non-operative management of fractures, but the results of these two comparisons are not necessarily generalizable due to variations in fracture pattern, assessment, and follow-up time. Therefore, comparative data that are relevant to the local population are important to know if the potential benefits of surgical fixation result in superior functional recovery over closed reduction and casting in the general orthopedic setting. The purpose of this study is to go beyond just radiographic fracture alignment and determine which treatment will result in better functional outcomes for patients. The purpose of this study was to compare functional outcomes for two methods of treatment of distal radius fractures: volar plate fixation and closed reduction and cast. To develop evidence that allows for the appropriate selection of treatment, optimize wrist function, and improve patient-centered recovery.

A comparative study was conducted prospectively at Altibri Medical College and Hospital, Karachi, Pakistan. The study was carried out for 6 months, starting on 1st December 2025 and ending on 30th May 2026. The sample size was calculated using the OpenEpi framework for comparing two independent means, with the mean DASH score as the primary outcome. In a previous Pakistani study conducted in 2023 by Ahmed et al., the mean score of DASH was found to be 16.6 in patients treated with volar locking plate fixation and 27.9 in patients treated with cast immobilization at 12 weeks, with a mean difference of 11.3 points between the two.[11] With a two-sided 95% confidence level, a Power of 80%, an equal allocation ratio of 1:1, and a mean difference of 11.3 points, the samples required were about 28 patients per group. The sample size was determined by allowing for a 10% loss to follow-up, which resulted in 31 patients in each treatment group and 62 patients total. A non-probability consecutive sampling technique was used to recruit eligible patients. Patients who presented with an acute closed distal radius fracture confirmed by radiologic examination were included if they were 18 years or older. Eligible patients were those who had either a volar fracture or a fracture that was displaced or unstable and were deemed suitable for either volar locking plate fixation or closed reduction and cast immobilization. Patients with informed consent and who consented to participate in the scheduled follow-up evaluations were recruited. Patients with open distal radius fractures, pathological fractures, previous fractures or significant pre-existing deformities of the affected wrist, previous wrist surgery or associated injuries that could have independent effects on upper-limb function were not included. Patients with pre-existing neurological or musculoskeletal disease of the injured UL, multiple major traumatic injuries, or cognitive impairment who were unable to provide reliable assessment of function were also excluded. Patients who declined participation or were unable to complete the required follow-up assessment were not included in the final analysis. After approval from the institutional ethics review committee, eligible patients were recruited from the Department of Orthopedic Surgery at Altibri Medical College and Hospital, Karachi. All participants signed informed written consent prior to participation. A structured data collection form was completed, and demographic and clinical data such as age, sex, occupation, affected wrist, dominant hand, mechanism of injury, fracture characteristics, and any medical history were noted. Fractures were confirmed using standard wrist radiographs, and the fracture pattern and displacement were documented. The patients who received volar locking plate fixation were treated with an open reduction and internal fixation procedure in accordance with the treating surgeon's protocol. The conservative treatment group had closed reduction and subsequent cast immobilization. Participants in both groups were given proper post-operative or post-reduction care and rehabilitation as advised by the treating team. At 12 weeks following treatment, the primary functional outcome was measured by the DASH questionnaire.[12] The DASH score ranged from 0 to 100, with higher scores indicating greater disability and lower scores indicating better functional outcomes. As secondary outcomes, wrist pain, range of motion, grip strength, and treatment-related complications were also recorded. To keep the assessment consistent, both groups had follow-up assessments performed with the same assessment method. Data were entered and analyzed using IBM SPSS Statistics, version 26. The Shapiro–Wilk test was used to assess normality of quantitative variables, which were presented as mean and standard deviation for normally distributed variables and median and interquartile range for non-normally distributed variables. Frequencies and percentages were used for qualitative variables such as sex, affected wrist, mechanism of injury, and complications. The independent-samples t-test was used to compare mean DASH scores between the volar plating and cast immobilization groups when the assumptions of normality and homogeneity of variance were satisfied. The Mann–Whitney U test was applied when these assumptions were not met. Categorical variables were compared by chi-square and fisher's exact tests. Between-group comparisons were performed, taking into account the possible differences in the baseline characteristics. A two-sided p-value of less than 0.05 was considered statistically significant.

A total of 62 patients with distal radius fractures were included in the analysis, with 31 patients in each treatment group. There were no differences between the two groups (volar plating vs casting) in the baseline demographic and clinical parameters evaluated, and the differences were not statistically significant. The distribution of fracture patterns, mechanisms of injury, affected wrist, and associated medical comorbidities was also similar between the groups (Table 1).

At the 12-week follow-up, the volar plating group had a significantly lower DASH score than the casting group. Wrist pain scores were also significantly lower, while wrist flexion and extension were significantly greater in the volar plating group. Volar plating was associated with significantly greater grip strength, with a p-value near the limit of significance. Functional outcomes between groups are reported in Table 2.

The overall complication rate was numerically lower in the volar plating group than in the casting group; however, the difference was not statistically significant. Tendon irritation and wound infection were observed in the volar plating group, whereas loss of reduction or malunion was recorded only in the casting group. Median nerve symptoms occurred in both groups. Treatment-related complications are compared in Table 3.

Table 1. Comparison of demographic and baseline clinical characteristics

Table 2. Comparison of functional outcomes at 12 weeks

Table 3. Comparison of treatment-related complications

In the present study, functional outcome after volar locking plate fixation was compared to cast immobilization in 62 patients with distal radius fracture and was evaluated at 12 weeks. The key finding was that patients undergoing volar plating had significantly better functional recovery when compared to those having casting. The mean Disabilities of the Arm, Shoulder and Hand (DASH) score was 16.6±10.5 in the volar plating group compared with 27.9±14.8 in the casting group (p=0.001), representing an 11.3-point difference in favor of surgical fixation. The volar plating group also had less wrist pain and more wrist flexion and extension. Volar plating resulted in an increase in grip strength, but it was not statistically significant (p=0.050). There were no significant differences between the number of complications overall after surgery and after casting. The results indicate the possibility of achieving quicker functional recovery during the early rehabilitation phase for volar plating procedures, while acknowledging the need to balance benefits with risks, costs, and patient-specific needs. The most significant results of this study were the reduction in the DASH score at 12 weeks after volar plating. The difference between the groups was 11.3 points, indicating less upper-limb disability after surgical fixation. This is in line with the study conducted by Ahmed et al. (2023) in Pakistan Journal of Medical & Health Sciences. The investigators measured mean DASH scores at 12 weeks after surgery, which were 16.6 for the operative group and 27.9 for the non-operative group, with a highly significant difference between the two groups (p<0.0001). These values are found to be the same as the present data set, which is also statistically consistent with the published Pakistani study.[11] The researchers in a multicenter randomized controlled trial from 2021 compared volar plate fixation with cast immobilization in patients with acceptable improvement in the intra-articular distal radius fracture. The operative group had superior patient-reported wrist outcomes at 6 weeks, 3 months, 6 months, and 1 year after surgery. There was also a large percentage of repeat surgery in the non-operative group. The early functional benefit reported in the current study is corroborated by findings that these fractures enjoyed in the present study, especially when they are intra-articular, where keeping the reduction acceptable may be difficult.[13] In 2022, a systematic review and meta-analysis was published which involved 1,368 patients across 12 RCTs. There was a significantly improved DASH score at the 3-month mark after volar plating (15.1 vs 25.06 in the pooled mean scores of the operative and casting groups, respectively). At longer follow-up, however, this difference was not significant, and there were no consistent conclusions about the benefits in terms of range of motion, grip strength, quality of life, or re-operation rates.[14] Another study, published in the Journal of the American Medical Association (JAMA) Network Open in 2023, found that the network meta-analysis of treatment strategies for distal radius fractures in older adults confirmed the results of this study. In the short-term and intermediate-term follow-up, the scores on the DASH and Patient-Rated Wrist Evaluation (PRWE) were lower for open reduction and internal fixation with a volar locking plate. These findings agree with the benefits of stable fixation for early functional recovery. However, variations in patient age, fracture stability, and function requirements might not have the same impact in every patient population.[15] The present study showed that the median pain score was lower in the volar plating group than in the casting group (2 (1–3) vs. 3 (2–5), respectively, p=0.018). This difference could be due to the benefits of early wrist mobilization and stable fracture fixation. But the pain outcome needs to be understood in the context of the rehabilitation protocols, the use of analgesics, and the severity of the fracture, which can also affect recovery. Thorninger et al. in the 2022 VOLCON randomized controlled trial compared the volar plating with cast immobilization in patients’ ≥ 65 years. At the primary follow-up evaluations, they did not detect statistically significant differences in pain or in patient-reported functional outcomes between the two groups, though there was an advantage in wrist flexion/extension recovery for operative treatment initially. Complication rates were also similar between groups: 20.9% following surgery and 16.6% following non-operative treatment (p=0.78).[16] Wrist mobility was also evaluated: 55° of median flexion and 60° of median extension after volar plating and 45° of median flexion and 50° of median extension after casting. These differences were statistically significant for both. The results are similar to the 2024 systematic review and meta-analysis conducted by Li et al., who found improved wrist ROM after volar plating at certain follow-up times, such as increased wrist flexion and supination at 3 months. The review also detected improved DASH scores at multiple follow-up time points, but the magnitude and consistency of benefit were different across age groups.[17] This increased range of motion found in the present study could be clinically significant, as wrist flexion and extension are involved in dressing, lifting, personal care, and occupational activities. However, statistical significance does not allow for the determination of the functional significance of the differences observed. Assessment against a predefined clinically important difference, assessment against the mobility before the intervention, and assessment at a longer time point would give a more complete interpretation. In older patients, Yang et al. (2024) conducted a meta-analysis to assess long-term postoperative results of volar locking plates and cast immobilization. Volar plating was significantly superior to cast/resin in the pooled DASH and PRWE scores and grip strength at follow-up of at least two years, without any significant difference in quality of life or reoperation rates in four randomized controlled trials with 423 participants.[18] The findings of the current study also need to be interpreted in the context of the evidence that the value of surgery is influenced by patient age and functional needs. The researchers compared multiple treatment options for unstable distal radius fractures in older adults (those aged 60 years and older) in the 2021 Wrist and Radius Injury Surgical Trial (WRIST). There were no significant differences between the groups of patients with respect to patient-reported outcomes at 24 months. The results showed that the alignment of the radiograph was less favorable in the selected older patients, but casting was shown to yield satisfactory long-term function.[19] Likewise, a retrospective analysis published in 2023 of patients >75 years of age who suffered intra-articular DRF showed that volar locking plate fixation was superior to cast immobilization. This study compared functional results and pain and underscored the need to consider the interplay between anatomic restoration and functional gain in the elderly. This population was significantly older than the population in the current study and cannot be directly compared.[20] Strengths and limitations The strength of the present study was its prospective comparative design, the documentation of the demographic and clinical characteristics, and the evaluation of the functional outcomes, with the use of a standardized questionnaire. The DASH score was also used as the main outcome measure, which also provided a patient-centered assessment of disability, along with pain, wrist mobility, grip strength, and complications related to treatment. The extra-articular fractures, as well as the intra-articular fractures, are included, which also represent the spectrum of presentations seen in the typical orthopedic consult practice. Several limitations should be acknowledged. First, the relatively small sample of 62 patients makes the results difficult to interpret with regard to statistical power, especially for complications and subgroup analysis. Second, the non-probability consecutive sampling technique and lack of reporting of random allocation eliminate the possibility of ruling out selection bias and confounding. The overall baseline characteristics were similar, but differences in the type and severity of the fracture, type of treatment received, adherence to rehabilitation, or functional demands of the treatment could have affected the results. Thirdly, the follow-up period was 12 weeks only; longer-term function, late complications, post-traumatic arthritis, reoperation, and return to work were therefore not assessed. Finally, the study took place in one center, so results may not be generalizable to other populations and health-care contexts. Multicenter studies with larger numbers of patients, longer follow-up, uniform rehabilitation, and clinically relevant confounders would increase the evidence.

The present study has demonstrated that volar locking plate fixation was correlated with better functional outcomes at 12 weeks in patients with distal radius fracture as compared to closed reduction and cast immobilization. This suggests that surgical fixation may benefit the wrist early because of the lower DASH score, less wrist pain, and more wrist flexion and extension. The difference in grip strength between groups, however, was on the margin of statistical significance, and the overall complication rate was not significantly different between groups.