Background: There is no consensus on the surgical management of unstable distal radius fractures. In this systematic review and meta-analysis, we pool data from trials comparing external fixation and internal fixation for treatment of this injury.

Methods: We searched electronic databases and conference proceedings for published and unpublished trials. Two authors independently screened titles and s, reviewed manuscripts, graded methodological quality, and extracted all relevant information from eligible studies. Data were pooled using fixed-effects and random-effects models with standard mean differences (SMD) and risk ratios for continuous and dichotomous variables, respectively. Heterogeneity across studies was assessed with Forest plots and calculation of the I2 statistic. Subgroup analyses were defined a priori and performed where appropriate.

Results: We pooled data from nine comparative trials, totaling 750 patients (360 fractures treated with external fixation and 397 with internal fixation). Initially, we found substantial heterogeneity between studies and no significant difference according to our primary outcome measure, validated patient-reported outcomes (SMD=0.20, 95% confidence interval=[−0.12, 0.51], p=0.22, I2=65%). However, when we grouped studies by plate type, we eliminated heterogeneity within each subgroup and found locking volar plates demonstrated significantly better patient-reported outcomes compared to external fixation (SMD=1.30, 95% CI=[0.74, 1.86], p< 0.00001, I2=0%). Additionally, we found internal fixation yielded significantly better recovery of forearm supination and restoration of volar tilt (SMD=0.31, 95% CI=[0.15, 0.47], p=0.0002, I2=0; SMD=0.57, 95% CI=[0.57, 0.78], p< 0.00001, I2=0, respectively). Subgroup analyses showed external fixation yielded better wrist flexion among randomized studies (SMD= 0.43, p< 0.003, 95% CI=[ 0.67, 0.20], I2=0), and there was no significant difference in grip strength among studies with high methodological quality (SMD= 0.08, 95% CI=[−0.34, 0.18], p=0.54, I2=0%).

Conclusions: Open reduction and internal fixation of unstable distal radius fractures yields greater recovery of forearm supination, better restoration of anatomic volar tilt, and, for locking volar plates in particular, superior patient-reported function. External fixation may result in better wrist flexion, but no difference exists in terms of grip strength.