Most orthopedic surgeons are currently focused on the physical aspect of healing, which is the primary concern for fracture patients [26,27,28]. On the other hand, the psychological dimension is frequently overlooked in the realm of fracture surgery. This is particularly true regarding surgical approach selection, which often entails choosing between internal fixation and external fixation operations. Herein, we clinically found that in DRF patients, the EFG had shorter operation times, smaller incision lengths, and less intraoperative blood loss than the IFG. However, regarding VAS pain scores, the IFG showed more significant pain reduction than the EFG at seven days and one-month post-surgery. There was no difference between the two methods in healing rates [26]. Conversely, significant variations were found in the patients’ long-term psychological states postoperatively, potentially due to the differing surgical approaches. Specifically, compared to the IFG patients, the EFG patients were more prone to negative emotions such as anxiety and depression, as well as insomnia at seven days, one month, and three months postoperatively. Additionally, while there were significant differences in PCS and MCS scores between the two groups at seven days, one month, and three months postoperatively, both groups showed positive change over time.

Internal and external fixation are both excellent therapeutic modalities, especially after decades of development in fracture treatment. Each has its advantages based on different indications. External fixation is crucial for open fractures, given its simplicity, flexibility, and minimal tissue damage. It has been widely used in clinical practice and has particularly demonstrated benefits in treating limb fractures with poor soft tissue conditions [29]. Moreover, external fixation significantly reduces complications such as infections as well as skin and soft tissue necrosis that could result from open reduction internal fixation, making it indispensable in limb lengthening procedures and the treatment of limb fractures with severe soft tissue injury and infection [30]. The intersection of indications for both methods has gradually expanded with continuous advancements in orthopedic medical concepts (external and internal fixations), especially with the introduction of the “Biological Osteosynthesis (BO)” principle [31, 32], leading to more controversies related to surgical method selection. However, when treating DRF, we believe that the choice of fixation method should still be based on the specific circumstances of the fracture. When there is significant shortening of the radius and partial metaphyseal bone loss or comminution, or in cases of compressive fractures, external fixation with appropriate traction to maintain or restore the height of the radius can be employed. This approach is particularly suitable for middle-aged and elderly patients, as it can avoid the need for a second surgery that might be required with internal fixation. Conversely, internal fixation is generally preferred when there is no significant shortening of the radius. Previous research [33,34,35] has often focused on exploring the physiological treatment effects while overlooking the psychological aspects. Offering a new angle to elucidate the respective impacts on patient emotions postoperatively, this study evaluates the psychological status of patients who have undergone internal and external fixation over multiple periods. Besides offering orthopedic surgeons a secondary basis for surgical method selection beyond absolute indications, this analysis provides a reference for the optimal timing of psychological interventions when patients experience adverse emotions.

According to previous research [36,37,38,39], external fixation devices can effectively control the position and stability of fractures, thereby promoting healing. However, these external fixators must often be maintained on the skin for some time, which may cause discomfort and pain, as well as a high probability of pin tract infections [40, 41], consequently leading to psychological discomfort for the patients. Furthermore, patients may feel unattractive due to external fixators, affecting their self-esteem, sleep, and psychological state [13, 42, 43]. Our results also indicate that the EFG patients are more likely to experience negative emotional reactions such as anxiety, worry, irritability, depression, and feelings of inferiority in the first three months post-surgery. Follow-up with a large patient cohort revealed that these negative emotional reactions are mainly associated with various factors related to the inconvenience and discomfort of wearing the external fixator. Additionally, practical concerns such as restricted mobility, difficulty bathing and dressing, and judgmental looks from others can further exacerbate the negative emotions in trauma patients, with severe cases even leading to suicidal thoughts [14, 15]. Moreover, patients’ sleep quality (as manifested by easy awakenings at night, poor nighttime sleep quality, and shortened total sleep time) could be affected [44]. During the interviews, we observed more pronounced anxiety, depression, and insomnia in EFG patients who were the primary source of family income and experienced financial difficulties. This area of concern will require additional research in the future. On the other hand, patients who underwent internal fixation surgery did not show significant anxiety, depression, or insomnia. This finding may be because internal fixation patients experienced less pain and discomfort, resulting in less significant negative psychological impacts compared to external fixation patients [45]. Additionally, patient acceptance is an important aspect. Engaging in manageable activities during postoperative recovery is crucial for the patients’ psychological adjustment. Internal fixation patients can participate in a more diverse range of social activities post-surgery, to some extent mitigating the impact of the operation on their QoL and alleviating anxiety and depression [45, 46].

A period of emotional accumulation is often required for psychological changes. From a temporal perspective, patients perceive the most significant increase in indicators such as HADS and AIS to occur at seven days postoperatively compared to preoperatively. Although patients are comprehensively informed about the surgical procedure beforehand, witnessing the Schanz screws directly connected to the body surface is initially difficult to accept. Therefore, some patients may experience stress and anxiety, and most patients may postoperatively experience sleep disturbances due to the subconscious protection of the external fixation frame. Sleep disturbances can set off a vicious cycle of low mood and worrying about the illness.

Patients exhibit the most prominent signs of anxiety, depression, and insomnia at one month postoperatively. This indicates that clinical psychological interventions are most effective within the first month after fracture surgery. If circumstances allow, psychological counseling should be initiated immediately within the first week post-surgery when the HADS and AIS indicators rise the fastest. At this point, healthcare professionals could provide appropriate psychological support and counseling, enhancing the patients’ self-awareness and cognitive abilities, which in turn reduces their worries, fears, and feelings of depression, helping them to better adapt to the postoperative recovery process [47]. Moreover, Jacobs et al. found a significant correlation between psychological factors and the body’s recovery process [48]. In this regard, providing timely psychological treatment to patients not only holds social significance but also contributes to functional recovery. Certain external factors (including the prolonged wearing of external fixation devices and postoperative pain) gradually diminish in their impact on some patients after the first month postoperatively, leading to changes in the patients’ psychological state and sleep patterns. As a result, some patients could return to the hospital to get the external fixation devices loosened and may also gain confidence from their satisfactory recovery. The loosening of external fixation devices one month post-surgery involves adjusting the bilateral ball heads and the central connecting slide bar of the ORTHOFIX external frame. The aim is to facilitate early functional exercises, maintain the height of the radius, and prevent joint stiffness. Interestingly, the support provided by external fixation during these early exercises can lead to improved functional activity. For most patients with distal radial fractures, the external fixator is removed 1–2 months after surgery. However, there is a subset of patients whose fractures have not yet fully healed. These fractures, such as those at the distal radial metaphysis and the radial diaphyseal transition zone, tend to heal more slowly. For these patients, the time for removal of the fixator can be extended to three months. This extension is predicated on ensuring that patients carry out functional exercises. These patients require psychological counseling during follow-up visits. However, this psychological improvement may vary to some extent based on factors such as ethnicity, region, and age groups included herein.

Primarily based on patients’ subjective opinions, QoL measurement could be the most crucial approach for assessing their postoperative physical and psychological functional recovery [49]. Herein, we found that the IFG patients had higher PCS and MCS scores at seven days, one month, and three months postoperatively compared to the EFG patients. Specifically, the IFG patients had significantly higher scores in items related to moderate activities, shopping, bathing and dressing oneself, limitations in desired activities, and increased difficulty in completing tasks in the PCS section. They also had significantly higher scores in items related to reduced work hours due to emotional reasons, impact on normal interactions with family and friends due to emotional reasons, feeling down, and feeling exhausted in the MCS section. Furthermore, despite having the greatest increase in the PCS and MCS scores between the seventh day and the first month postoperatively, the EFG exhibited lower PCS and MCS scores at three months compared to preoperative levels. Other studies on postoperative QoL found that increases in PCS and MCS scores mostly occur within the first six months postoperatively [50, 51]. Based on stable reduction, both internal and external fixation could result in satisfactory fracture recovery in the short term postoperatively [4,5,6,7,8]. However, the time it takes for patients to return to their previous functional status in society varies. In addition to psychological factors, this discrepancy could be influenced by the practical impact of daily behavioral hindrances of wearing external fixation devices. Furthermore, patients wearing external fixation devices could subjectively feel they can still not engage in daily activities and perform regular duties.

According to previous research [52,53,54] patients with higher postoperative QoL tend to have higher happiness indices, are less susceptible to anxiety, depression, and insomnia, and are better positioned for physiological recovery, as well as better interpersonal and social interactions. External fixation can negatively impact patients’ postoperative QoL, leading to an increased incidence of low mood, fatigue, melancholy, and social limitations due to external scrutiny (such as reluctance to communicate with friends and family and reduced social activities). The duration of wearing an external fixator generally falls within an acceptable range for most DRF patients. However, compared to internal fixation, statistically significant negative emotional differences have been observed in external fixation. Special attention should be paid to monitoring emotional changes in patients requiring long-term external fixation procedures, such as bone lengthening [55]. An external fixator may lead to difficulties in daily activities, such as mobility issues and grooming. Therefore, healthcare professionals should offer practical assistance and guidance on dressing and other aspects of daily living to help patients better adapt to wearing an external fixator and adjust to their new life situation [56]. Moreover, guiding patients who have undergone external fixation surgery to actively participate in rehabilitation activities could help them better adapt to wearing the external fixator, boost their confidence and self-esteem, and reduce the incidence of negative emotions.

Our study primarily aimed to provide new insights into the selection of surgical procedures for fracture patients from multiple dimensions, including psychological status, sleep, and QoL. In conclusion, compared to external fixation surgery, internal fixation surgery has a smaller impact on the emotional state, sleep, and QoL of fracture patients during postoperative recovery. This outcome is mostly due to subjective acceptance of long-term wearing of external fixation devices, restricted daily activities, and longer recovery time. Notably, the above conclusion does not mean internal fixation is superior to external fixation. The two approaches have different indications, and external fixation has its irreplaceable advantages. It is crucial to recognize that the choice between external fixation and internal fixation often hinges on the specific characteristics and requirements of the fracture type, such as open versus closed fractures. This distinction in indications suggests a potential variability in the applicability of these treatments, which could influence the study’s outcomes. To address this, our analysis carefully considers the fracture types and conditions across patient groups to minimize potential biases. However, orthopedic surgeons must seriously consider the potential psychological impact of external fixation on patients’ post-surgery. The results of a randomized controlled trial led by the Major Extremity Trauma Research Consortium (METRC) suggest that even in the case of severe open tibial fractures, the routine use of modern external ring fixation for treatment should be avoided. Patients with poor psychological baselines may require timely psychological intervention if negative emotions worsen within the first week following external fixation treatment [57]. Notably, internal fixation surgery may be a better choice when both internal and external fixation can be performed on a patient with a fragile psychological health status. In such cases, surgical outcomes and risks, as well as individual patient factors, should remain the primary considerations. Overall, our study findings provide insight into the psychological impact of different fixation procedures on fracture patients. Doctors should be aware of the potential external fixation-induced adverse psychological events and provide patients with timely intervention and the best treatment plan possible.

This study has certain limitations. First, the sample size was relatively small, necessitating multi-center studies with larger sample sizes to better generalize the findings in the future. Second, recall bias was inevitable despite using well-validated questionnaires such as HADS and SF-36. Third, the overall patient compliance decreased after the removal of the implant despite our efforts to conduct long-term patient follow-ups at six months postoperatively and beyond, making it difficult to assess the patients’ psychological status over a longer period. Based on these drawbacks, future research could explore the impact of internal fixation and external fixation surgeries on the psychological status of patients with various types of fractures, as well as different age and gender groups, and consider longer follow-up periods.