Volar Locking Plate Versus External Fixation for Distal Radius Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract

Distal radius fractures (DRFs) are among the most common fractures of the upper extremity, and management remains controversial. Both volar locking plate (VLP) and external fixation (EF) are widely used. We aim to compare functional, radiographic, and safety outcomes between VLP and EF in the treatment of DRFs to guide evidence-based management. We systematically searched PubMed, Scopus, Web of Science, and Embase through October 2025 for English-language RCTs comparing VLPs versus EFs in adults with DRFs. Quality assessment was performed using the Cochrane Risk of Bias tool (version 2). Meta-analysis was conducted using RevMan 5.4. Heterogeneity was assessed using I² statistics, and random-effects models were applied when I² exceeded 50%. Nine randomized controlled trials (RCTs) involving 1,023 patients were included. VLP showed better early functional recovery, with significantly lower Disabilities of the Arm, Shoulder, and Hand (DASH) scores at month 1 (mean difference (MD) = -7.94, p = 0.009) and month 6 (MD = -4.26, p = 0.010). Grip strength favored VLP at 3 months (MD = 5.35, p = 0.002), 6 months (MD = 5.30, p = 0.002), and 1 year (MD = 2.96, p = 0.005). Wrist range of motion (ROM) also favored VLP across all time points, with improvements in MD of 4.18 degrees over 3 months and 2.73 degrees over 12 months. Radiographic evaluation indicated that VLP achieved greater volar tilt (MD = 1.84, p = 0.02), whereas EF resulted in better ulnar deviation (MD = -0.82, p = 0.001). VLP had a significantly higher risk of reoperation (RR = 2.51, p < 0.0001). VLP fixation provides earlier functional recovery and better wrist mobility than EF in the management of DRFs. EF, however, is associated with a lower overall risk of reoperation. Although long-term functional outcomes and radiographic parameters are comparable between the two techniques, VLP offers clear short-term advantages, supporting its use when early functional restoration is a priority.