20 Distal Radius Fracture in the Elderly
Abstract
Distal radius fractures (DRFs) are typical fractures seen in relatively fit persons with osteoporotic bone. Considering the increasing life expectancy of the elderly population, appropriate management of these fractures is of growing importance. Generally, tolerance for anatomical deviations is higher, mostly due to decreased functional needs. Surgical indication should include factors such as patient’s age, functional demand (return to sport activities), patient’s comfort (short immobilization time), preinjury daily activity level, lifestyle requirements (cosmetically appearance), current medical conditions, and stage of osteoporosis. If decision for surgery is made, volar locking plate fixation for dorsally displaced DRFs is the appropriate treatment option. Distraction plate, hemiarthroplasty, and initial shortening and palmar plate fixation of DRF with primary Sauve-Kapandji procedure are alternative treatment possibilities.
20.1 Introduction
Distal radius fractures (DRFs) are typical fractures seen in relatively fit persons with osteoporotic bone. Traditionally, DRFs in older patients have been treated with closed reduction and cast immobilization. 1 Considering the increasing life expectancy of the elderly population, appropriate management of these fractures is of growing importance. Restoration of wrist function, allowing a rapid return to an active and independent lifestyle is the major goal of treating elderly.
Decision-making for surgical or nonsurgical approach to osteoporotic DRFs is difficult. These decisions are often made on the basis of data from treatments of much younger patients. 2 Some authors have suggested that unstable DRFs should be managed nonoperatively because fracture reduction and anatomical alignment on X-rays are not correlated with better functional outcomes in older adults. On the other hand, several case series have documented excellent results of internal fixation with very low complication rates of dorsally displaced DRF with the use of locking implants in older population. 3
The impact on the function of an individual patient is variable and can be difficult to predict. Generally, tolerance for anatomical deviations is higher mostly due to decreased functional needs. DRFs are a good example illustrating how decision-making in older patients should differ considerably:
Older patients are a heterogeneous group with diverse demands.
Comorbidities contribute to increased perioperative risk.
Consequences of malunited fractures are much less predictable and often clinically insignificant (▶Fig. 20.1).
20.2 Indications
Currently there is no consensus regarding the best treatment for unstable DRFs in the older population. 4 Decision-making for operative or nonoperative treatment must involve patient’s general health condition (e.g., comorbidities, daily activity level, independent living, taking care of somebody) and functional demand (e.g., sports activity, practiced yoga, using walking aids). Some patients require a cosmetically acceptable wrist posture without any visible deformity that should be included in the consideration for further treatment.
Apart from patient-related factors mentioned above, fracture-related factors might conduct to further treatment options. Primary reduction of the fracture is considered to be acceptable when dorsal tilt does not exceed 20 degrees, radial shortening is not more than 3 mm, and intra-articular step-off does not exceed 2 mm. 5 Fracture instability is also defined as a failure to hold the reduced position of the fracture within the forearm cast with a loss of reduction at 1 or 2 weeks. Osteoporosis weakens the metaphyseal bone by decreasing trabecular bone volume. 6 Therefore, osteoporotic DRFs very often show a large metaphyseal defect or void that increases fracture instability. 7 Nesbitt et al reported that the age was the only statistically significant risk factor in predicting secondary displacement and instability while treating DRFs by closed reduction and immobilization. The risk for displacement with an unacceptable radiographic result was found to increase in patients older than 58 years. 8 Sakai et al reported a significant correlation between increasing displacement of distal fracture fragment and lower bone mineral density (BMD). 9
For palmarly displaced DRFs where the carpus follows the palmar fracture fragment leading to malalignment relative to the forearm shaft, for DRFs combined with distal ulnar fracture and involvement of all three columns that leads to a highly unstable situation, and for open fractures, we recommend standard operative fixation even in older adults.
20.3 Treatment Options
Spanning plate as a treatment option is mentioned in Chapter 10.
20.3.1 Closed Reduction and Cast Immobilization
Current protocol for nonoperative treatment of DRFs includes initial fracture reduction under local or general anesthesia in the emergency department and then immobilization with a below-forearm splint. After the primary swelling has decreased, the slab is converted to a complete below-elbow cast at 1 or 2 weeks. Secondary loss of primary reduction can occur up to 2 weeks after primary closed reduction. In these cases, repeated manipulation, especially in the osteoporotic bone, is insufficient and correlated with the incidence of complex regional pain syndrome (CRPS) type 1 and thus is not advised. 5 In total, the wrist is immobilized in a forearm cast in neutral position of the wrist for 5 weeks. Active and passive finger motion is encouraged early. A therapy program after cast removal including active assisted motion of the wrist and grip strengthening is started at 5 weeks.
20.3.2 Closed Reduction and Percutaneous Pinning
Pinning alone may not be enough to maintain articular and metaphyseal support, as Kirschner wires (K-wires) are not load-bearing devices. In addition, a forearm splint is necessary to neutralize the bending forces across the metaphysis. The wires are left up to 4 weeks and the forearm cast is worn for 6 weeks. Percutaneous pinning is a relatively simple method of fixation that is recommended for reducible extra-articular and simple intra-articular DRFs without metaphyseal comminution and with good bone quality. In multifragmented intra-articular fractures with impacted joint fragments, it is quite difficult to reduce these fragments by percutaneous pinning. Azzopardi et al concluded that percutaneous pinning of unstable, extra-articular DRFs provides only minimal improvement in the radiographic parameters compared with immobilization in a cast alone. This did not correlate with an improved functional outcome in older adults. 10
20.3.3 External Fixation
External fixation (EF) as treatment option for DRFs was primary reserved for highly unstable and severely comminuted fractures. This technique relies on ligamentotaxis, which indirectly pulls the fracture fragments out to length through longitudinal traction. The joint spanning (wrist bridging) implant with fixation in the radius diaphysis and the metacarpal does not directly address the reduction and maintenance of the dorsal tilt and intra-articular fragments of the distal fracture fragment. The other option of application of EF in DRFs is the nonbridging technique where the distal pins are placed into the distal fracture fragment without spanning the wrist joint. This technique limits joint stiffness and maintains the reconstructed dorsal tilt but is only applicable where there is sufficient space in the distal fragment.
Complications associated with EF are pin-track infection and iatrogenic lesion of the superficial radial nerve. Overdistraction of the wrist joint may lead to CRPS. Usually the EF is applied for 6 weeks. Especially in osteoporotic bone quality with weak hold of the pins, loosening of the pins occurs quite early so they have to be removed before definitive bone healing. Adults with cognitive impairment do not easily tolerate and facilitate compliance with treatment using EF and weight bearing or range of motion (ROM) limitations, making complications due to EF more likely. Considering these issues, we no longer use percutaneous K-wire fixation or external fixation as definitive treatment option for treating unstable DRF in the elderly.
20.3.4 Volar Locking Plate Fixation
Volar locking plates are like an internal fixator unloading the usually comminuted dorsal metaphyseal bone. In a biomechanical study, the volar fixed-angle plate proved efficient in restoring the normal axial force distribution, superior to conventional palmar and dorsal T-plate fixation. 11 The fixed-angle screws lock into the plate and do not rely on engagement of the screw threads in bone leading to better fixation in osteoporotic bone. The other advantage of locking plates is the good subchondral support of the distal fragments even in very short distal fracture fragments. The latest generation of locking plates offer the option of variable locking screws that allow a total angulation of 30 degrees for screw placement.
The most appropriate plates should be selected to correspond with the fracture pattern. There is no single plate that is universally successful or devoid of any potential complications for all types of unstable DRFs, including intra-articular and extra-articular fracture patterns. Fragment-specific fixation and double-plate fixation techniques may be helpful to treat various fracture types, especially intra-articular fractures with a large metaphyseal void (▶Fig. 20.2).
Surgical Technique
Surgery may be performed under a brachial plexus block or with use of general anesthesia and an upper arm tourniquet. The distal part of the radius is exposed through a Henry palmar approach between the flexor carpi radialis tendon and the radial artery. After the release of the pronator quadratus muscle, the fracture site is exposed. Careful reduction of fracture fragments is performed, as poor bone quality can lead to iatrogenic fractures. Reduction is achieved with the assistance of an image intensifier and the fracture is temporarily stabilized with K-wires. The locking plate is placed on the palmar cortex and is first fixed at the gliding hole to allow appropriate positioning for the image-controlled subchondral placement of the locking screws. Care must be taken to place the plate proximal to the watershed line. In intraarticular fractures, wrist arthroscopy may be used to assess intra-articular steps and associated soft-tissue injuries. In comminuted intra-articular fractures, the locking screws are placed in the most distal subcortical position to act as a subcortical buttress against fracture subsidence. The subcortical bone plate retains greater loading capacity than the osteopenic compressed cancellous metaphyseal bone. Especially with variable locking plate systems, which allow approximately 30 degrees of screw insertion, intra-articular screw placement can be performed quite easily. If fracture instability demands distal placement of hardware, close follow-up investigations and hardware removal should be considered at first sign of flexor tendon irritation. Intraoperatively, the lateral tilt X-ray, with the wrist angulated 20 to 30 degrees, is performed to check the plate and screw position and it may detect intra-articular screw position or very distal plate position. The “dorsal horizon view” (▶Fig. 20.3) is used to detect excessively long screws penetrating the dorsal cortex. 12 If possible, the pronator quadratus muscle is reinserted to cover the plate.
Postoperatively, the wrist is immobilized in a below-the-elbow splint for pain reduction. Active digital ROM is started immediately. Ten days after surgery, the sutures are removed and the wrist is placed in a removable splint for another week. At that time, physiotherapy with active and passive wrist mobilization out of the splint is started. No immobilization is necessary in extraarticular metaphyseal and in simple intra-articular DRFs as a stable fixation can be achieved intraoperatively.
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