Another surgical option for ORIF is dorsal plating. The advantage of dorsal plating for intra-articular fractures is that it allows visualization of the joint surface without disruption of the stouter volar carpal ligaments and the risk of future instability of the radiocarpal joint. In volar lunate facet fractures, fragment-specific fixation may be used. An internal distraction plate that uses ligamentotaxis to obtain reduction is particularly beneficial in patients with fractures that extend into the radial diaphysis and in polytrauma patients who may require load bearing through the wrist for mobilization. A distraction plate has also been effective in the treatment of comminuted, osteoporotic distal radius fractures.22 This plate is removed after 12 weeks with good functional outcomes.23
Volar locked plating has improved radiographic outcomes in terms of radial shortening, volar tilt, and radial inclination, with a low complication rate reported.24 Clinically, it was also associated with improved function, improved grip strength, and decreased pain in the first 6 months compared with dorsal plating.24 Furthermore, compared with volar locked plating, dorsal plating had a higher risk of secondary fracture displacement and extensor tendon irritation in up to 30% of cases.25 Volar plating also showed superior radiographic and clinical results compared with percutaneous wire and external fixations in elderly patients.2,26
To support the joint surface in elderly patients with comminuted fractures and metaphyseal bone loss following restoration of length and alignment, bone graft substitutes are often used. The quality of the bone, the size of the bone defect, blood flow to the fracture site, and the method of fixation and/or immobilization affect the healing process and the maintenance of the reduction.27 Given the added morbidity associated with autogenous bone grafting, materials such as hydroxyapatite, tricalcium phosphate, and biphasic calcium phosphate have been used. The use of allograft bone is advantageous because of its osteoconductive and osteoinductive properties, but it lacks the osteogenic nature of autograft. In addition, allograft also lacks the same degree of structural properties of autograft. Allograft bone does represent a reasonable alternative if autograft is not available. Citing the unique scaffolding properties of hydroxyapatite, a subcategory of allograft, Hegde et al28 used this graft in 27 patients aged >50 years with distal radius fractures. They reported improved range of motion and maintained radial length (ie, no collapse) at 16-week follow-up. Although no graft is ideal, Ozer and Chung27 recommend the use of iliac crest bone graft in cases of major bone loss and nonunion and calcium phosphate and allograft bone chips in other cases. Calcium phosphate may work well in elderly patients because of ease of use, relatively low cost, and the potential to provide structural support and thus satisfactory healing and functional recovery.27
The optimal postoperative physical therapy regimen for patients who sustain distal radius fractures is still debated, and there is considerable variability between home-based and formal hand therapy programs.29 One systematic review examined the differences between formal therapy and home therapy and found equal benefits among patients without surgical complications.30 Souer et al31 found pain to be the most important independent predictor of disability in patients who underwent volar locked plating. In their cohort, formal physical therapy did not improve average disability scores or motion after 6 months, suggesting that patients may benefit from more active and autonomous therapy versus a passive approach that limits progress according to pain tolerance. However, certain patients may benefit from therapy provided by a certified hand therapist, including those with decreased finger motion, advanced age, and various comorbidities including osteoarthritis, carpal tunnel syndrome, and complex regional pain syndrome (CRPS).29 Early finger range of motion can help to prevent stiffness, a major complication of immobilization following distal radius fractures.
Lutz et al32 compared the complications associated with nonsurgical and surgical management of distal radius fractures in elderly patients. The authors found that, of 258 patients with an average age of 74 years who were identified in a prospective database, the most common surgical complication was surgical site infection (12%), and the most common nonsurgical complication was median neuropathy (11%). CRPS, extensor tendon rupture, and device irritation were also reported.32
Malunion is another complication associated with nonsurgical treatment, with reported rates as high as 89%3 and obvious deformity noted on physical examination. In a systematic review of unstable distal radius fractures in elderly patients, worse radiographic outcomes were reported in patients with fractures treated nonsurgically; however, functional outcomes were similar between patients who were treated surgically and those treated nonsurgically.4 Major complication rates were higher for fractures treated surgically. Although patients often have minimal pain and disability following nonsurgical treatment,3,32 the possibility of cosmetic deformity must be discussed with them early to inform the treatment decision-making process (Figure 4).
Multiple studies have shown no difference in clinical outcomes of nonsurgical versus surgical treatment (regardless of fixation strategy) of distal radius fractures in elderly patients.5-7 Patients treated surgically appear to have better grip strength than do those treated nonsurgically, but they demonstrated no difference in the ability to perform activities of daily living.7 In a recent randomized prospective trial comparing volar locked plating with closed reduction and cast immobilization in patients aged >65 years, the surgical group showed better wrist function in the early postoperative period.10 However, at 6 and 12 months, there was no significant difference in wrist function or pain between groups. At all time points, grip strength was considerably better in the surgical group.10
Overall, patient satisfaction with surgical treatment remains high. In terms of cost, surgical treatment is more expensive than nonsurgical treatment. Shauver et al33 performed an economic analysis of treatment of distal radius fractures in patients aged ≥65 years. Although ORIF was more expensive than casting, surgery was found to be worthwhile in terms of cost per quality–adjusted life-year.
After fracture of the distal radius, pain, grip strength, and range of motion may continue to improve for up to 4 years after injury.9 Despite the potential for cosmetic deformity associated with distal radius fractures in the elderly and an initial decline in independence that necessitates assistance with activities of daily living, patients are able to adapt and regain much of their functionality. In the setting of distal radius malunion, long-term functional outcomes are not affected, even among highly active persons. In a cross-sectional study of 96 patients aged ≥60 years, Nelson et al34 found no significant difference between those with a well-aligned fracture and those with distal radius malunion in terms of Disabilities of the Arm, Shoulder, and Hand (DASH) score, visual analog scale function, strength, or wrist motion at 1-year follow-up. A study of “superelderly” patients (defined as those aged ≥80 years) with and without malunion following treatment of distal radius fractures found that the ability to perform activities of daily living, wrist pain, return to a normal level of function, grip strength, and range of motion were comparable.35 However, Rozental et al36 found that the survival rate after distal radius fractures was only 57% at 7 years compared with 71% for a matched cohort without fracture at 7 years. This effect was even more pronounced in men; the reasons for this finding have not been elucidated but may relate to the overall shorter lifespan of men compared with women.36
Special Considerations for Patients With Osteoporosis
In the elderly population, distal radius fractures are considered to be related to osteoporosis. In a Scandinavian sample, the prevalence of osteoporosis among females who experienced a distal radius fracture was 34% compared with 10% in control subjects.37 In a retrospective review of patients who sustained distal radius fractures, 64% were diagnosed as having osteoporosis/osteopenia following screening.38 Patients with a distal radius fracture also had an increased rate of hip and other osteoporotic fractures,39 an incidence attributed to architectural bone changes and more active lifestyles11 as well as balance difficulties and heightened risk of falls.
Because distal radius fractures typically occur many years before an osteoporotic hip fracture,40 they may serve as a tool to identify patients with a heightened risk of more debilitating fractures, allowing appropriate lifestyle modifications and medical treatment to decrease this risk. Bone mineral density (BMD) testing is commonly a prerequisite to specialty referral, and patients who sustain or have a history of these fractures should be referred for baseline osteoporosis assessment, including possible evaluation by an endocrinologist and a bone densitometry scan. Given the rising burden of osteoporotic disease and its sequelae, a comprehensive screening program would benefit many patients. According to the International Society for Clinical Densitometry and the National Osteoporosis Foundation, screening should involve BMD testing for all women aged ≥65 years and for men aged ≥70 years.41
Compared with patients with normal BMD, those with osteoporosis are at increased risk of early instability, malunion, and late carpal malalignment after distal radius fracture.42 In a retrospective study of 64 postmenopausal women treated with ORIF for distal radius fractures, the mean DASH scores of those with osteoporosis were 15 points higher than the scores of patients with osteopenia. There was no significant difference in range of motion or radiographic data between the two groups, yet the osteoporotic group had a higher rate of complications.42
An inverse relationship has also been established between BMD and the severity of distal radius fractures.42,43 Unlike fragility fractures of the hip or lumbar spine, distal radius fractures allow for reduction and monitoring of the alignment, making them more amenable to objective comparisons. Maintaining an anatomic reduction is important for any patient, and close follow-up within 1 to 2 weeks of closed reduction facilitates determination of definitive treatment on the basis of fracture displacement. In a retrospective review of 78 patients aged >65 years with closed reduction of distal radius fractures, no relationship was found between BMD and the ability to maintain reduction in a splint.40 However, in another study, despite reduction, fracture displacement returned to injury alignment with respect to radial height and ulnar variance in more than half of patients, whereas volar tilt was maintained in more patients.37
Treatment options for patients with osteoporotic distal radius fractures include diphosphonates and calcium and vitamin D supplementation in addition to lifestyle modifications. In a randomized trial of 50 women aged >50 years, early initiation (ie, within 2 weeks of injury) of diphosphonate therapy in those with osteoporotic distal radius fractures treated surgically did not appear to affect fracture healing or clinical outcomes, including DASH score, wrist motion, and grip strength.44 However, the use of volar locked plating to achieve primary bone healing in these patients may have subverted the potential deleterious effect of diphosphonates on callus formation.
At our institution, elderly patients with distal radius fractures are often referred for further testing, especially if preliminary laboratory test results, including calcium, vitamin D, phosphorus, and magnesium, are normal. In patients for whom the underlying cause of poor bone health is incompletely understood, referral to metabolic bone experts is suggested.
Vitamin C supplementation has also received attention for its proposed effect on preventing CRPS following distal radius fractures, a complication observed in approximately 10% of patients.45 Through its action on oxygen free radicals, vitamin C is thought to inhibit local proinflammatory cascades via antioxidant mechanisms. Although the 2010 AAOS guidelines included a moderate strength recommendation for the use of vitamin C as an adjunct for pain control,18 more recent studies and meta-analyses have not corroborated the correlation between supplemental use and the incidence of CRPS.44,46
Debate exists regarding the role that vitamin D plays in distal radius fractures. Low vitamin D levels may be associated with distal radius fractures in adults, independent of BMD. In a case control study of men and women, an inverse dose-response relationship between vitamin D and distal radius fractures was observed, showing that low vitamin D levels were a predictor of fractures independent of BMD.47 In a recent prospective study of postmenopausal patients with distal radius fractures, up to 50% of those with a fragility fracture did not have osteoporosis as demonstrated by BMD testing; however, the authors found no significant difference in vitamin D levels between the fracture group and the control group.48 Higher levels of bone turnover markers, such as total procollagen type 1 N-terminal propeptide and osteocalcin, were observed in the fracture group, suggesting that monitoring bone turnover markers may be more useful in predicting fracture risk than monitoring vitamin D levels alone.48
Future Directions and Summary
The incidence of osteoporosis-related fractures is increasing as the aging population expands. To date, no consensus exists regarding the treatment of distal radius fractures in elderly patients. The goals of treatment are to provide a painless limb with good function. Although surgical treatment improves alignment, radiographic assessment does not appear to be associated with better clinical outcomes. Further research should more precisely target the molecular substrates of bone resorption without disrupting osteoblast function in order to preserve and maintain bone mass. Attention has been focused on identifying risk factors for osteoporosis and on early preventive strategies aimed at maintaining and improving bone health. Evaluation and screening for osteoporosis should be undertaken in all elderly patients, BMD testing should be done, and necessary treatments should be initiated to prevent osteoporosis-related fractures. This type of management represents a paradigm shift to preventive rather than reactive medicine, and the orthopaedic surgeon should play a key role in this transition.
Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, references 10, 43, and 44 are level I studies. References 15, 29, 33, 38, 39, and 42 are level II studies. References 4, 31, 32, 34, 37, and 40 are level III studies. Reference 22 is a level IV study.
References printed in bold type are those published within the past 5 years.
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Keyword: elderly; distal radius fracture; malunion; osteoporosis© 2017 by American Academy of Orthopaedic Surgeons