Meta-analysis of RCTs is generally considered to provide the strongest evidence of clinical interventions [23
] and has more advantages than observational research studies and single randomised trials. Observational research studies, regardless of the integrity and care with which they are conducted, are open to bias, and single randomised trials are often limited by relatively small sample sizes and resulting imprecision in the estimates of treatment effects. In our meta-analysis, we included the only ten eligible RCTs according to explicit inclusion criteria and believe our results to be valid. Nevertheless, there are limitations to meta-analysis. One is that of publication bias. Insofar as funnel plots could show, our study is not subject to this bias. Another issue is study heterogeneity, both in the nature of the studies themselves and in the statistical heterogeneity of individual RR. Various epidemiological studies have shown an increasing incidence of unstable distal radius fractures with age, starting at around 40 years, in women. A prospective survey [24
] of patients aged ≥35 years with Colles’ fracture at six centres in the UK for a period of one year reported the overall incidence of this fracture to be 9/10,000 in men and 37/10,000 in women. Therefore, although there may be effect modification due to mean age and proportion of women, we could not determine this from available data.
According to the best estimates from our meta-analysis, IF reduced the incidence of total surgical complications and pin-track infections after one year of follow-up. Pin-track infection in the IF group results from the use of adjunctive K wires to attain the best possible stabilisation [8
]. Infections are often associated with open pin sites [14
]. Pin loosening also was responsible for the higher risk of pin-track infection. The number of complications for the palmar locking-plate fixation ranged from 0% to 10% [25
]. Schmelzer-Schmied [27
] also considered it was better than that of external fixation. However, the incidence of extensor pollicis longus rupture was higher after IF, possibly because the hardware lies in direct contact with the extensor tendons [28
]. Dobretz [31
] reported this complication in up to 12% of cases when using the palmar locking plate.
With regard to grip strength, we used a fixed-effects model in the meta-analysis. There was no significant heterogeneity between studies (I2
50%), as shown in Fig. . Our pooled results showed that grip strength, values of which are given as the percentage of the value for the uninjured side, was superior in the IF group at six weeks and three months postoperatively. For DASH score, the random-effects model was used, and significant heterogeneity existed (I2
50%), as shown in Fig. . DASH score was superior in the IF group at three months and one year follow-up. The better clinical results with IF in our study may be due to the higher rigidity of the fixation, which enables faster rehabilitation. Regardless of the method of reduction and stabilisation, early restoration of wrist function is the goal of treatment for distal radius fractures [32
Radiographic outcomes, the given values of which were compared with those for the contralateral extremity, may affect functional outcome [33
]. It is the surgeon’s goal to restore the distal radius to its normal anatomical alignment and congruity. How accurately this is achieved can be measured from radiographs by comparing volar tilt angle, radial inclination etc. with published normal values [34
]. In our study, radial inclination and ulnar variance were superior in the IF group three months postoperatively.
In summary, we suggest that the final results are significant and that there is some evidence supporting the use of ORIF, although not enough for use in most decisions necessary in managing distal radius fractures. Limitations remain, and results need to be further verified by more high-quality trials. For better results, we need to more carefully consider issues of long-term outcomes and intraoperative and preoperative factors and report them in a reliable, consistent and standardised manner.