Impact of Time-to-Surgery on Adverse Outcomes for Distal Radius Fractures: A Population-Based Study.

Abstract

Objectives: To determine the optimal time window for surgical fixation of acute, isolated distal radius fractures (DRFs) in order to minimize postoperative complications.

Methods: Design: Retrospective, population-based cohort study.

Setting: Province-wide analysis using administrative health databases in Ontario, Canada.

Patient selection criteria: Adult patients (≥18 years) who underwent surgical fixation for acute, isolated DRFs (OTA/AO 2R3) between 2010 and 2020 were included. Patients with open fractures, polytrauma, neurovascular injury, or fractures marked as urgent were excluded. Wait time to surgery was defined as days from emergency department presentation to operative intervention.

Outcome measures and comparisons: The primary outcome was a composite of complications including any complication or revision surgery within 10 years. Secondary outcomes included infection and revision individually. Wait time to surgery was analyzed both as a continuous variable and as a categorical variable. For the categorical analysis, patients were stratified into seven intervals (0-2, 3-5, 6-9, 10-15, 16-20, 21-25, and 26-30 days). These cut-offs were chosen to provide relatively small, evenly distributed time ranges while maintaining sufficient patient numbers within each group to ensure statistical power and model stability. This approach allowed for meaningful comparisons across the surgical wait-time spectrum while complementing the continuous analysis. Cox multivariable models were used to estimate hazard ratios (HRs), adjusting for demographics, comorbidities, fracture and fixation type, surgeon volume, and hospital type. An instrumental variable analysis using institutional wait times was performed to address confounding by indication.

Results: A total of 13,389 patients met inclusion criteria. Patients were predominantly female (71.2%) with a mean age of 55.7 years (Range 18-95). The 0-2 day group served as the reference and demonstrated the highest complication rates. Compared with this group, patients treated within 6-20 days had a significantly lower risk of composite complications, with the greatest benefit observed in the 6-9 day (HR 0.84, 95% CI: 0.73-0.97, P=0.02) and 10-15 day (HR 0.78, 95% CI: 0.67-0.90, P=0.001) subgroups. Infection risk was similarly lowest in the 6-15 day window, with the most favorable outcomes in the 10-15 day subgroup (HR 0.59, 95% CI: 0.41-0.84, P=0.003). Institutional-level analysis showed a 30% lower infection risk for treatment within 6-15 days compared to 1-5 days (HR 0.70, 95% CI: 0.56-0.87, P=0.002). Surgeries delayed >25 days showed a non-significant trend toward worse outcomes (HR 1.10, 95% CI: 0.75-1.32, P=0.88).

Conclusions: Surgical fixation of distal radius fractures within 6-15 days was associated with the lowest observed rates of composite complications and infection. These findings suggest that this timeframe may represent an optimal window for intervention. By evaluating multiple discrete time points, this study contributes to the understanding of "when to operate," complementing prior literature focused primarily on delayed surgery.

Level of evidence: Level III.