Research Article|Articles in Press

Is early mobilization after volar locking plate fixation in distal radius fractures really beneficial? A meta-analysis of prospective randomized studies

Published:December 28, 2021DOI:


      • We determined that the early mobilization of a distal radius fractures after volar locking plate fixation did not provide any benefit in pain relief for the patient.
      • However, patients who underwent early mobilization have more favorable disability of the arm, shoulder, and hand scores and higher grip power at 6 weeks, 3 months, and 6 months postoperatively, though the difference narrowed with time.
      • Early mobilization improves the postoperative range of motion compared to late mobilization at 6 weeks and 3 months postoperatively, but does not show an advantage at 6 months postoperatively.


      Study design

      This was a systematic review with a meta-analysis.


      Despite rising trends toward surgical treatment of distal radius fractures (DRF) with volar locking plate (VLP) fixation, there is a lack of consensus on when to start vigorous wrist range of motion (ROM) exercises after surgery.


      We performed a meta-analysis to compare early and late mobilization after VLP fixation in patients with DRF.


      Four prospective randomized controlled trials with a minimum of 6 months of follow-up were retrieved through MEDLINE (PubMed), EMBASE, Web of Science, the Cochrane Library, and the KoreaMed databases in March 2021. We divided patients into an early group (patients who started ROM exercises of the wrist within 2 weeks after surgery), and a late group (patients who started ROM exercises 5 or 6 weeks after surgery). The primary outcome was treatment efficacy which was measured through improvement in pain score, function score, ROM, and grip power. The secondary outcome was the incidence of postoperative complications.


      This meta-analysis included 127 patients in the early group and 131 patients in the late group. The outcomes were compared at 6 weeks, 3 months, and 6 months postoperatively. There was no significant difference in pain score, though the early group had a lower average visual analog scale score. The early group had a lower arm, shoulder, and hand disability score than the late group (95 % CI, -16.25 to -8.35 points; P < .001) at 6 weeks postoperatively, suggesting significantly superior outcomes. A similar trend persisted at 3 (n = 74 in the early group and n = 77 in the late group; 95% CI, -5.45 to -0.30; P = .029) and 6 months (n = 102 in the early group and n = 100 in the late group; 95% CI, -4.81 to 0.21; P = .073), but the differences were smaller. The early group had a higher grip power at all follow-up periods, but the difference was only significant at 6 months postoperatively (n = 88 in the early group and n = 83 in the late group; 95% CI, 0.50 to 6.99; P = 0.024). The early group also had more favorable ROM in all directions at 6 weeks, but only in supination at 6 months. The complication rate was not significantly different between the 2 groups. There were no differences in the rates of secondary operation and reduction loss.


      Early ROM exercise after VLP in DRF resulted in superior functional scores and grip power until 6 months postoperatively. The dominance of the joint ROM, which was seen at 6 weeks after surgery in the early exercise group, decreased with time and ultimately showed little difference at 6 months. Early exercise is safe and did not increase complication rates.


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        • Jakob M
        • Rikli DA
        • Regazzoni P.
        Fractures of the distal radius treated by internal fixation and early function. A prospective study of 73 consecutive patients.
        J Bone Joint Surg Br. 2000; 82: 340-344
        • Chung KC
        • Spilson SV.
        The frequency and epidemiology of hand and forearm fractures in the United States.
        J Hand Surg Am. 2001; 26: 908-915
        • Ruch DS
        • McQueen MM.
        Distal radius and ulna fractures.
        in: Bucholz RW Beaty JH Rockwood CA Green DP Rockwood and Green's Fractures in Adults. Vol 1. eds. Wolters Kluwer Health/Lippincott, Williams & Wilkins, Philadelphia, PA2010: 829-880
        • Corsino CB
        • Reeves RA
        • Sieg RN.
        Distal Radius Fractures. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2020.
        StatPearls Publishing LLC., 2020
        • Chung KC
        • Shauver MJ
        • Birkmeyer JD.
        Trends in the United States in the treatment of distal radial fractures in the elderly.
        J Bone Joint Surg Am. 2009; 91: 1868-1873
        • Wilcke MK
        • Hammarberg H
        • Adolphson PY.
        Epidemiology and changed surgical treatment methods for fractures of the distal radius: a registry analysis of 42,583 patients in Stockholm County, Sweden, 2004-2010.
        Acta Orthop. 2013; 84: 292-296
        • Hevonkorpi TP
        • Launonen AP
        • Huttunen TT
        • Kannus P
        • Niemi S
        • Mattila VM.
        Incidence of distal radius fracture surgery in Finns aged 50 years or more between 1998 and 2016 - too many patients are yet operated on?.
        BMC Musculoskelet Disord. 2018; 19: 70
        • Shah GM
        • Gong HS
        • Chae YJ
        • Kim YS
        • Kim J
        • Baek GH.
        Evaluation and management of osteoporosis and sarcopenia in patients with distal radius fractures.
        Clin Orthop Surg. 2020; 12: 9-21
        • Orbay JL
        • Badia A
        • Indriago IR
        • et al.
        The extended flexor carpi radialis approach: a new perspective for the distal radius fracture.
        Tech Hand Upper Extrem Surg. 2001; 5: 204-211
        • Costa ML
        • Achten J
        • Rangan A
        • Lamb SE
        • Parsons NR.
        Percutaneous fixation with Kirschner wires versus volar locking-plate fixation in adults with dorsally displaced fracture of distal radius: five-year follow-up of a randomized controlled trial.
        Bone Joint J. 2019; 101 (-b): 978-983
        • Jeudy J
        • Steiger V
        • Boyer P
        • Cronier P
        • Bizot P
        • Massin P.
        Treatment of complex fractures of the distal radius: a prospective randomised comparison of external fixation 'versus' locked volar plating.
        Injury. 2012; 43: 174-179
        • McFadyen I
        • Field J
        • McCann P
        • Ward J
        • Nicol S
        • Curwen C.
        Should unstable extra-articular distal radial fractures be treated with fixed-angle volar-locked plates or percutaneous Kirschner wires? A prospective randomised controlled trial.
        Injury. 2011; 42: 162-166
        • Orbay JL
        • Fernandez DL.
        Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient.
        J Hand Surg Am. 2004; 29: 96-102
        • Twigt B
        • Bemelman M
        • Lansink K
        • Leenen L.
        Type C distal radial fractures treated with conventional AO plates: an easy and cost-saving solution in a locking plate era.
        Int Orthop. 2013; 37: 483-488
        • Krischak GD
        • Krasteva A
        • Schneider F
        • Gulkin D
        • Gebhard F
        • Kramer M.
        Physiotherapy after volar plating of wrist fractures is effective using a home exercise program.
        Arch Phys Med Rehabil. 2009; 90: 537-544
        • Foo TL
        • Gan AW
        • Soh T
        • Chew WY.
        Mechanical failure of the distal radius volar locking plate.
        J Orthop Surg (Hong Kong). 2013; 21: 332-336
        • Orbay JL.
        The treatment of unstable distal radius fractures with volar fixation.
        Hand Surg. 2000; 5: 103-112
        • Klein SM
        • Prantl L
        • Koller M
        • et al.
        Evidence based postoperative treatment of distal radius fractures following internal locking plate fixation.
        Acta Chir Orthop Traumatol Cech. 2015; 82: 33-40
        • Yoo JI
        • Cha YH
        • Kim JT
        • Park CH.
        Clinical outcomes of bipolar hemiarthroplasty versus total hip arthroplasty: assessing the potential impact of cement use and pre-injury activity levels in elderly patients with femoral neck fractures.
        Hip Pelvis. 2019; 31: 63-74
        • Andrade-Silva FB
        • Rocha JP
        • Carvalho A
        • Kojima KE
        • Silva JS.
        Influence of postoperative immobilization on pain control of patients with distal radius fracture treated with volar locked plating: A prospective, randomized clinical trial.
        Injury. 2019; 50: 386-391
        • Brehmer JL
        • Husband JB.
        Accelerated rehabilitation compared with a standard protocol after distal radial fractures treated with volar open reduction and internal fixation: a prospective, randomized, controlled study.
        J Bone Joint Surg Am. 2014; 96: 1621-1630
        • Watson N
        • Haines T
        • Tran P
        • Keating JL.
        A comparison of the effect of one, three, or six weeks of immobilization on function and pain after open reduction and internal fixation of distal radial fractures in adults: a randomized controlled trial.
        J Bone Joint Surg Am. 2018; 100: 1118-1125
        • Quadlbauer S
        • Pezzei C
        • Jurkowitsch J
        • et al.
        Early rehabilitation of distal radius fractures stabilized by volar locking plate: a prospective randomized pilot study.
        J Wrist Surg. 2017; 6: 102-112
        • Lozano-Calderón SA
        • Souer S
        • Mudgal C
        • Jupiter JB
        • Ring D.
        Wrist mobilization following volar plate fixation of fractures of the distal part of the radius.
        J Bone Joint Surg Am. 2008; 90: 1297-1304
      1. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation.
        Bmj. 2016; 354: i4086
        • Higgins JP
        • Altman DG
        • Gotzsche PC
        • et al.
        The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.
        Bmj. 2011; 343: d5928
        • Sterne JAC
        • Savovic J
        • Page MJ
        • et al.
        RoB 2: a revised tool for assessing risk of bias in randomised trials.
        Bmj. 2019; 366: l4898
        • Begg CB
        • Mazumdar M.
        Operating characteristics of a rank correlation test for publication bias.
        Biometrics. 1994; 50: 1088-1101
        • Egger M
        • Davey Smith G
        • Schneider M
        • Minder C
        Bias in meta-analysis detected by a simple, graphical test.
        Bmj. 1997; 315: 629-634
        • Becker BJ.
        Synthesizing standardized mean-change measures.
        Br J Math Stat Psychol. 1988; 41: 257-278
        • FB A-S
        • JP R
        • A C
        • KE K
        JS S. - Influence of postoperative immobilization on pain control of patients with distal.
        Injury. 2019; 50: 386-391
        • Valdes K.
        A retrospective pilot study comparing the number of therapy visits required to regain functional wrist and forearm range of motion following volar plating of a distal radius fracture.
        J Hand Ther. 2009; 22 (quiz 319): 312-318
        • Duprat A
        • Diaz JJH
        • Vernet P
        • et al.
        Volar locking plate fixation of distal radius fractures: splint versus immediate mobilization.
        J Wrist Surg. 2018; 7: 237-242
        • Zeckey C
        • Spath A
        • Kieslich S
        • et al.
        Early mobilization versus splinting after surgical management of distal radius fractures.
        Dtsch Arztebl Int. 2020; 117: 445-451
        • Martinez-Mendez D
        • Lizaur-Utrilla A
        • de Juan-Herrero J.
        Prospective study of comminuted articular distal radius fractures stabilized by volar plating in the elderly.
        Int Orthop. 2018; 42: 2243-2248