Distal Radius Fractures in the Elderly

Levin, L. Scott MD, FACS; Rozell, Joshua C. MD; Pulos, Nicholas MD

Journal of the American Academy of Orthopaedic Surgeons:
doi: 10.5435/JAAOS-D-15-00676
Review Article
Abstract

Distal radius fractures are common in elderly patients, and the incidence continues to increase as the population ages. The goal of treatment is to provide a painless extremity with good function. In surgical decision making, special attention should be given to the patient’s bone quality and functional activity level. Most of these fractures can be treated nonsurgically, and careful closed reduction should aim for maintenance of anatomic alignment with a focus on protecting fragile soft tissues. Locked plating is typically used for fracture management when surgical fixation is appropriate. Surgical treatment improves alignment, but improvement in radiographic parameters may not lead to better clinical outcomes. Treatment principles, strategies, and clinical outcomes vary for these injuries, with elderly patients warranting special consideration.

Author Information

From the Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

Dr. Levin or an immediate family member has received royalties from Mavrek; has received research or institutional support from AxoGen; and serves as a board member, owner, officer, or committee member of the American College of Surgeons, the American Society for Reconstructive Microsurgery, the American Society for Surgery of the Hand, the International Hand and Composite Tissue Allotransplantation Society, the United Network for Organ Sharing, the Vascularized Composite Allograft Transplantation Committee, and the World Society for Reconstructive Microsurgery. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Rozell and Dr. Pulos.

Received November 24, 2015

Accepted April 18, 2016

Article Outline

The distal radius is the second most commonly fractured bone in elderly persons and the most frequent upper extremity fracture in women aged >50 years. Most studies define the elderly as patients aged 50 to 75 years,1-10 a range that is used in this review. An increasingly active and expanding elderly population is responsible for the increased incidence of distal radius fractures over the past 40 years.11 Controversy remains as to whether these fractures should be treated surgically or nonsurgically. Aside from radiographic parameters of displacement and angulation, the decision to proceed to surgery depends on the patient’s functional outcome and activity level. Particularly in elderly patients, the potential for cosmetic deformity of the wrist after nonsurgical treatment may influence the personal decision to undergo corrective surgery.12 Regardless of the treatment modality, the goals of care are to improve pain and restore function.

An evidence-based review of the evaluation and treatment of distal radius fractures, the effects on healthcare costs, and preventive strategies reveals an intensified focus on maintaining and improving bone health in the growing elderly population.

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Epidemiology

Distal radius fractures account for up to 18% of all fractures in the elderly population.11 White race, female sex, and osteoporosis are risk factors for distal radius fractures. There may also be seasonal variations; elderly patients are predisposed to fracture in the winter months because of slippery walking conditions. Typically, the mechanism of injury is a fall onto an outstretched hand. Patients with intact cognitive and neuromuscular systems may have a higher risk of fracture because of their reflexive ability to reach out during a fall as opposed to falling onto their side.13

In 2007, distal radius fractures cost Medicare $170 million, or $1,983 per beneficiary.14 Although most distal radius fractures in elderly patients are managed nonsurgically, the use of internal fixation has increased in the United States. Internal fixation not only costs Medicare nearly three times as much as nonsurgical treatment,15 but it may also increase hospitalization rates and related expenses.

Despite the overall trend toward internal fixation for distal radius fractures, the practice varies demographically and geographically. In a study of Medicare beneficiaries, fractures were more likely to be treated surgically in women and in Caucasian patients.15 Furthermore, the use of internal fixation ranged from 4.6% to 42.1% among hospital referral regions, a nearly 10-fold difference. Patients treated by fellowship-trained hand surgeons were also more likely to undergo surgery.15

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Clinical Evaluation

The clinical history should include the mechanism of injury and presenting reports, such as pain, loss of function, and deformity. Information regarding hand dominance, hobbies, and occupation is equally valuable. It is important to ask about sequelae from previous trauma to the upper extremity or existing osteoarthritis that may limit the patient’s preinjury range of motion and function. Inquiry into the use of walking aids and independence in performing activities of daily living is crucial for a better understanding of the demands on the elderly patient’s upper extremities and may influence treatment decisions.

A systematic examination of the hand and wrist should progress distally to proximally. The vascular status of the hand should be assessed by verifying digital capillary refill and radial and ulnar pulses at the wrist. The sensory examination should include two-point discrimination values and the ability to detect light touch in the median, ulnar, and radial nerve territories. The presence of any paresthesia or numbness in the median distribution warrants careful attention because acute carpal tunnel syndrome has been reported in 5.4% to 8.6% of all distal radius fractures.16 The motor examination, which may be limited secondary to pain, should evaluate the anterior and posterior interosseous nerves as well as the radial nerve proper and median and ulnar nerves. The examiner should also note the presence of lacerations or skin tears to rule out an open fracture, ecchymosis, edema, or angular deformities (eg, dinner fork deformity). Skin tearing is very common in elderly patients with thin soft tissues, and care must be taken, especially during closed reduction, to avoid shearing of these tissues.

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Radiographic Evaluation

Three radiographic views of the hand and wrist (ie, AP, lateral, and oblique) are usually sufficient to identify most distal radius fractures. Important radiographic parameters to assess include, but are not limited to, angulation, rotational deformity, shortening, comminution, and joint alignment. Specifically for distal radius fractures, parameters include radial inclination (22°; mean, 19° to 29°), radial height (11 to 12 mm), and volar tilt (11°; mean, 11° to 14.5°).17 Radiographs of the forearm and elbow also should be obtained to detect more proximal injuries or elbow instability. After closed reduction and splinting, the clinician should obtain radiographs documenting appropriate restoration of the previously mentioned parameters. CT is increasingly used by hand surgeons as a diagnostic aid or to better quantify fracture patterns (ie, intra-articular, impaction, shear fragments) and to aid in surgical planning. CT may also be used when revision surgery, such as corrective osteotomy for malunion, is considered.

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Management

In the most recent American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline on distal radius fractures, the Workgroup was unable to recommend for or against surgical treatment of these fractures in elderly patients.18 The recommendation regarding volar locked plating versus percutaneous pinning was also graded “inconclusive.” Kodama et al8 created a scoring system to aid in surgical decision making for distal radius fractures. For patients aged ≥50 years, important factors include fracture pattern, radiographic parameters, age, hand dominance, and occupation. In a multiple logistic regression analysis, the authors found close correlations between clinical outcome and comminution of the dorsal cortex and the volar cortex after reduction, ulnar neck fracture, volar tilt before and after closed reduction, and ulnar variance after closed reduction.8 Although this scoring system may be used to guide treatment, it has yet to be prospectively validated.

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Nonsurgical

At our institution, minimally displaced fractures are initially placed in a sugar tong plaster splint (including the elbow joint) to limit supination and pronation (Figure 1). Fractures with substantial displacement are treated with closed reduction and are immobilized in a sugar tong splint. On the palmar aspect of the hand, the splint ends just proximal to the metacarpal heads, allowing early finger range of motion to prevent stiffness and preserve mobility. Limited compression with the elastic bandage wrapping holds the splint in place. Fracture characteristics determine the preferred closed reduction maneuver. Analgesia is provided by the emergency department staff, and a hematoma block is infiltrated directly into the fracture site, if possible.We place our patients in finger-trap traction before reduction to fatigue the deforming muscular forces surrounding the wrist. The index and long fingers are placed in the traction device coincident with the linear alignment of the radiocarpal joint so as not to exacerbate any deformity. In general, the mechanism that is causing the deformity is recreated, and the mechanism is reversed. Multiplanar ligamentotaxis involves the combined use of longitudinal traction and palmar translation of the hand on the forearm to allow the capitate to rotate on the lunate, thereby tilting the distal radial fragment in a palmar direction.19 In the coronal plane, radioulnar translation realigns the distal fragment onto the radial shaft.19 The typical Colles fracture reduction involves placing a thumb over the fracture site as a lever, hyperextension of the fracture fragment to disengage it from the radial metaphysis, longitudinal traction, and flexion to lever the dorsally displaced fracture fragment into position. In elderly patients with fragile skin and soft tissues, care is taken to prevent skin tearing; this can often be avoided by placing a piece of cotton cast padding between the patient’s skin and the physician’s fingers at the wrist during the reduction. Finally, a careful neurovascular examination is repeated after reduction.

All patients are instructed to follow up in 1 week for repeat radiographs. In patients who undergo definitive nonsurgical treatment, a short arm cast is applied, and the patient is assessed weekly for the first several weeks to evaluate for secondary displacement or collapse of the fracture. Conversion to a cast decreases the overall bulk of the splint and allows increased range of motion and thus less stiffness. However, secondary displacement of distal radius fractures upon conversion to a cast is still a risk; overall secondary displacement is more common in elderly patients and is reportedly as high as 89%.20 In osteoporotic patients treated nonsurgically, the cast serves more for fracture support and pain alleviation than for anatomic reduction.7

Nondisplaced distal radius fractures in the elderly may have a lower chance of subsequent displacement; however, at our institution, these patients are typically scheduled for weekly follow-ups for 4 to 6 weeks after injury to assess for secondary collapse. At the follow-up visits, cosmetic deformity of the wrist is discussed. Because of the limited amount of soft tissue, the patient should understand that his or her wrist may not appear as it did before injury. In a study of 13 women aged >71 years, McQueen and Caspers21 reported that 12 had a mild to moderate cosmetic deformity at least 4 years after injury. Arora et al7 reported that, despite this clinical appearance, many elderly patients—especially those with low demands—are able to live with their deformity.

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Surgical

Surgical treatment options for distal radius fractures in elderly patients include closed reduction and external fixation or percutaneous Kirschner wire fixation and open reduction and internal fixation (ORIF) using a volar or dorsal locking plate or a dorsal bridge plate (Figure 2). Although frequently used, the locked volar plate is not without complications (Figure 3).

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

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Postoperative Rehabilitation

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.

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Outcomes

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

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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

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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.

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References

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