Epidemiology: Fractures of the distal radius are the most common upper extremity fracture sustained in the elderly population. The incidence of these fractures is expected to increase in the future with increasing cost to the healthcare system.
Nonsurgical Treatment: Conservative treatment has been shown to correlate with radiographic malunion, cosmetic deformity, and diminished grip strength. However, a number of studies have demonstrated that despite these issues, functional outcomes including DASH and PRWE are equivalent to operative treatment.
Surgical Treatment: While operative treatment has been shown to result in superior radiographic outcomes and early improvement in grip strength, final functional outcomes were equivalent to conservative treatment. More recently, studies have shown not only improved radiographic outcomes but also functional improvement in the older population.
Practice Patterns: While evidence remains unclear as to which patient would benefit from operative intervention, surveys demonstrate that a greater proportion of fractures are being treated operatively than would be expected based on outcomes data. The completion of a Hand Surgery fellowship strongly correlates with operative treatment.
Contemporary Indications: More recent randomized controlled trials have demonstrated improved functional and radiographic outcomes following operative treatment as compared to conservative treatment in the more active older aged patient. It has been shown that in displaced, unstable fractures, both functional and radiographic outcomes are superior to nonoperative treatment with equivalent complication rates.
A 72-year-old otherwise fit and active woman falls onto her outstretched right (dominant) arm while walking her dogs. She is seen in the ER where imaging is obtained demonstrating a right distal radius fracture ( Fig. 1 ). She undergoes reduction and splinting and presents to clinic for repeat evaluation in 7 days. Her repeat imaging is shown ( Fig. 2 ) with loss of height and worsening dorsal angulation. When discussing operative vs nonoperative treatment what are the expected outcomes for this patient?
Importance of the Problem
Fractures of the distal radius are increasingly common, resulting in a cost of $170 million to Medicare alone. They represent the most common fracture of the upper extremity and are the second most common fracture overall in women > 60 years of age. With increasing life expectancy in most societies, the incidence of distal radius fractures (DRFs) has been steadily increasing over the past 40 years, particularly in the elderly population (defined as patients > 65 years of age). The lifetime risk of a Caucasian woman > 60 sustaining a DRF is 15% (compared to 2% for men). Thus, the injury burden imposed by fractures of the distal radius on society, particularly the elderly population, looms large. Radiographic parameters for operative vs nonoperative treatment have been well established for patients < 65; however, consensus has yet to be reached regarding the optimal treatment for patients > 65 years of age. As clinical information continues to evolve, identifying evidence-based, cost-conscious practices will be essential for the sustainability of health systems worldwide.
What are the outcomes of operative vs nonoperative treatment of DRFs in the elderly population?
Historically, the majority of research has demonstrated that conservative treatment of DRFs resulted in equivalent clinical and functional outcomes with significantly fewer complications. Recently, several articles have supported operative intervention (with the use of anatomically shaped angular stable plate fixation) in these patients, challenging prior literature supporting conservative management. In general, the incidence of operative treatment of DRFs in patients > 65 years of age is increasing, particularly by surgeons with subspecialty train in hand surgery. Proponents of conservative treatment cite equivalent functional outcome scores and a lower complication rate. Proponents of operative fixation note increased grip strength and less cosmetic deformity (primarily with a volar locked plate), as well as earlier return to function.
Finding the Evidence
The following Pubmed search algorithms were used to construct this chapter:
(((((((((“Radius fractures”[Mesh] OR distal radius fracture*[tiab]))) AND ((“Geriatrics”[Mesh] OR elder* OR older*)))) AND ((*operative OR conservative OR *surgical)))))).
Articles were reviewed for relevance to the clinical question as well as study format and results. Articles were included if there was a full-text available in the English language.
Quality of the Evidence
Thirty-three total studies were found which specifically addressed patient outcomes between operative and nonoperative management of DRFs in elderly patients. Owing to the comparative nature of the clinical question, no level IV studies were included. The level of evidence in relation to these studies were:
Level I :
Randomized trials: 9
Level II :
Prospective cohort studies: 3
Level III :
Systematic Reviews/Metaanalyses of level I–III data: 5
Retrospective cohort studies: 12
Overview of Level I Evidence
There were no systematic reviews or metaanalyses which specifically focused on DRFs in the elderly and analyzed level I data. Nine randomized-controlled trials were included.
The RCTs included in the current review reflect overall trends of distal radius fixation. The two oldest studies compared external fixation with nonoperative treatment and found differences in radiographic but not functional outcomes. Moroni et al. (2004) randomized 40 elderly osteoporotic women with extraarticular DRFs and found that patients in the external fixation group had better preserved volar tilt and radial height at 6 weeks ( P = .008) with no difference in SF-36 scores at 3 months. Roumen et al. (1991), by contrast, randomized 101 Colles’ fractures in patients greater than age 55 years and found similarly improved radiographic values based on the Lidstrom scale with no difference in functional outcomes, grip strength, nor any correlation between radiographic or functional parameters.
Subsequent RCTs examined percutaneous pinning compared to nonoperative management with similar results compared with external fixation. Azzopardi et al. (2005) randomized 57 patients age 60 years or above with extraarticular DRFs to percutaneous pinning versus nonoperative management and found significant differences in radial height ( P = .03), inclination ( P = .05), and volar tilt ( P = .03) at 1 year; however, no differences were reported in SF-36, pain, or activities of daily living scores. Similarly, Wong et al. (2010) randomized 60 patients above age 65 years with extraarticular DRFs to pinning versus nonoperative management. They found higher rates of preserve radial height, inclination, and volar tilt in the percutaneous pinning group ( P < .05), but no differences in quality of life or Mayo wrist scores.
More recent RCTs have focused on volar locked plating in comparison with nonoperative management. Two studies found no significant advantage of surgical over nonoperative management. The earliest of these was Arora et al. (2011), who randomized 73 patients with AO type A or C DRFs to volar locked plating or nonoperative management. Radiographic parameters were significantly improved in the operative group with improved volar tilt (3.0 vs − 10.4 degrees, P = .0001), radial inclination (21.2 vs 15.9 degrees, P < .0001), ulnar variance (0.7 vs 3.2 mm, P < .0001), and articular stepoff (0.2 vs 0.6 mm, P = .02). Clinical outcomes at 1 year, however, showed no difference in DASH, PRWE scores, or range of motion, but did demonstrate improved grip strength in the operative group (22.2 vs 18.8 kg, P = .02). Of note, complications including tendon rupture or irritation because of screw or plate placement was significantly higher in the operative group ( P < .05), while the nonoperative group had five cases of complex regional pain syndrome compared to two in the operative group. Bartl et al. (2014) found similar results in their study of 185 patients greater than 65 years of age with AO type C fractures. Radial inclination (20.3 vs 17.7 degrees, P = .0005), volar tilt (5.1 vs − 3.7 degrees, P < .001) at 3 months were similarly improved in the operative group; however, SF-36, DASH, and ROM parameters were not significantly different between the two groups at 1 year. Notably, 37 fractures randomized to nonsurgical treatment had subsequent loss of reduction requiring revision for a 41% conversion rate to surgical treatment, with C3 fractures having a 2.1 higher relative risk (95% CI 1.1 to 3.8) of conversion compared with C1 or C2 fractures.
By contrast, three more recent RCTs found advantages beyond radiographic improvement in volar locked plating compared with nonoperative treatment. Martinez-Mendez (2018) examined 90 patients above age 60 years with AO type C DRFs and found improved PRWE (17 vs 30, P = .03) and DASH (16 vs 28, P = .04) scores at 2 years, as well as improved supination (85 vs 72 degrees, P = .01) and pronation (84 vs 71 degrees, P = .01) in the operative group. There was no difference in grip strength (64% casting vs 73% plating, P = .15). One patient in the nonoperative group developed CRPS. By contrast, two patients in the operative group required secondary operation, one for carpal tunnel syndrome and another for extensor pollicis longus tendon rupture. Saving et al. (2019) examined 140 patients above age 75 years with AO A or C DRFs types and similarly found better PRWE (7.5 vs 17.5, P = .014), DASH scores (8.3 vs 19.9, P = .028), and grip strength (96.8% vs 80.0%, P = .001) in the operative group which was accompanied by improved radiographic parameters. They found no difference in complications between groups for either major (needing secondary operation, 14% operative, 11% nonoperative, P = .6) or minor complications (20% vs 11%, P = .19). Sirnio et al. (2019) found similar results in 80 patients over age 50 years with AO types A and C (excluding C3) fractures, with operatively treated patients exhibiting lower DASH scores compared with nonoperative treatment at 2 years (7.2 vs 14.4, P = .0005). However, this difference may not be clinically significant. There was no significant difference in grip strength between the operative and nonoperative group (− 1 kg, 95% − 2 to 4). One case of Carpal tunnel syndrome required surgical release in the operative group, and three patients (two Carpal tunnel syndrome, one malunion) required secondary operation in the nonoperatively managed group.
Overview of Level II Evidence
There was one prospective cohort analysis that examined outcomes in elderly distal radius fractures in operative versus nonoperative management. The multicenter Wrist and Radius Injury Surgical Trial (WRIST) was a multicenter international study that was intended as a randomized controlled trial of surgical methods on DRFs in patients above age 60. Included fractures were unstable fractures which warranted surgical fixation, however, as part of the study, 117 of the 304 eligible participants opted for casting. Twelve-month follow-up demonstrated that the casting group had a relative risk of 1.88 (1.22–2.88) of developing any complication ( P < .01); however, this association was not significant when limited to moderate (requiring nonsurgical intervention) or severe (requiring surgical intervention) complications. The WRIST investigators also examined outcomes of the Michigan Hand Outcomes Questionnaire (MHQ) and found that opting for casting did not have a significant effect on 12-month outcomes, nor did outcomes correlate with radiographic improvements ( Table 1 ).