Key Points
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Distal radius fractures primarily affect children, young adults, and the elderly.
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The incidence of distal radius fractures is increasing worldwide.
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Understanding the epidemiology of distal radius fractures helps guide treatment.
Panel 1: Case Scenario
A 65-year-old, right hand dominant female visited the emergency room with a swollen and deformed right wrist after a fall on an outstretched hand when she slipped on a wet floor at home. Radiographs reveal an intraarticular distal radius fracture with 30 degrees of dorsal angulation. How does the description and treatment of this fracture change if the patient is 10 or 25 years old?
Importance of the Problem
Upper extremity fractures are one of the most common injuries around the globe, with an estimated frequency of 67.6 fractures per 10,000 persons in the United States. Distal radius and ulna fractures are the most common upper extremity fractures, occurring in 16.2/10,000 persons. Although the incidence of distal radius fractures (DRFs) is increasing across all age groups, they are most common in the pediatric and elderly populations. Research indicates that the first peak in the rate of DRFs occurs in the adolescent years. The second increase starts among adults greater than 50 years of age and peaks in the seventh to eighth decade of life ( Fig. 1 ). DRFs comprise about 25% and 18% of all fractures in the pediatric and elderly populations, respectively.
Gender and racial differences also exist among DRF patients. Fig. 2 shows the gender distribution of DRFs by age. Males have a higher incidence of fractures in the 0–19-year age group and females have a higher incidence in the 40–64-year age group. DRFs are also more common in woman than men with age > 65, especially among Caucasians.
An understanding of the heterogeneity of the DRF population helps surgeons provide better treatments that are tailored to unique patient characteristics. Assessing the epidemiology of DRFs is also critical in efforts to prevent these costly and debilitating injuries.
Main Question
How does the epidemiology of distal radius fractures help guide treatment?
Current Opinion
Pediatric DRFs rarely require anatomic reduction because children have remaining growth potential. On the other hand, young adult intraarticular DRFs often develop posttraumatic arthritis whether treated operatively or nonoperatively. Controversy also exists regarding operative versus nonoperative management of DRFs in the elderly population.
Finding the Evidence
We identified articles that were published in the last 10 years. English, French, and German language studies were included.
The search results in PubMed are as follows:
“epidemiology of distal radius fracture” = 0
epidemiology of distal radius fracture = 387
“Radius Fractures/epidemiology”[Mesh] AND distal = 131
epidemiol* AND distal AND (radius OR radial) AND fracture* = 401
Total after removing duplicates = 412
The search results in Web of Science are as follows:
“epidemiology of distal radius fracture” = 1
epidemiology of distal radius fracture = 283
Total after removing duplicates = 283
No relevant articles were identified in the Cochrane database
Quality of the Evidence
There is no level I or level II evidence available since epidemiology is mainly descriptive, looking at the incidence and distribution of health conditions; in this case, distal radius fractures.
Importance of the Problem:
Level III:
Systematic reviews of case series, case control, and retrospective comparative studies: 15
Pediatric Findings:
Level III:
Systematic reviews of case series, case control, and retrospective comparative studies: 18
Level V:
Expert opinion and summary of current concepts: 2
Young Adult Findings:
Level III:
Systematic reviews of case series, case control, and retrospective comparative studies: 5
Level V:
Expert opinion and summary of current concepts: 1
Elderly Findings:
Level III:
Systematic reviews of case series, case control, and retrospective comparative studies: 14
Level V:
Expert opinion and summary of current concepts: 2
Findings
The Pediatric Population
The incidence of distal radius fractures in children and adolescents varies across studies but may be as high as 25%–33% of all fractures in this population. Beattie et al. reported a fracture rate of 20.2/1000 children. Females and males accounted for 39% and 61% of their patient population, respectively, and 33% of fractures involved the distal radius/ulna. Randsborg et al. found a similar incidence of 18.0 fractures/1000 children less than 16 years of age. DRFs accounted for 31% of all fractures in their study. Additional articles also reported a higher incidence of DRFs in male versus female children.
The increasing overall incidence of DRFs in the pediatric population is well-documented. Landin, in a large study of pediatric fractures, suggested that increased sports participation contributed to an increase in fracture rate between 1950 and 1970. De Putter et al. corroborated this in their study of Dutch children between 1997 and 2009. The authors found an increase in sports-related activities, soccer, and inline skating in particular, correlated with an increase in DRFs. In addition to sports-related causes, trauma and falling onto an outstretched hand are hypothesized mechanisms of injury. It is also possible that the increasing incidence of fractures is a result of better fracture detection methods and improved access to care.
The literature indicates that the maximum fracture rate occurs at the age of puberty. In the 1960s, Alffram and Bauer found the peak age for forearm fractures to be 10–14 years of age. For DRFs specifically, Bailey et al. identified peak ages of 11.5–12.5 and 13.5–14.5 for girls and boys, respectively. Chung and Spilson identified a peak around 10 years of age. Furthermore, Beattie et al. reported a bimodal distribution of DRFs with peaks at ages 6–7 and 13–14. The higher occurrence of DRFs during puberty is likely related to bone mineral density at the distal radius during the growth spurt. Faulkner et al. demonstrated that the incidence of DRF coincides with a decline in size corrected bone mineral density and that gains in bone area precede the gain in bone mineral content. The imbalance between bone strength and linear growth may explain why minor falls from standing height cause fractures in this age group.
Skeletally immature individuals have remaining growth and remodeling potential. Therefore, anatomic reduction of the distal radius is rarely indicated. Casting alone is typically effective. Two studies with level III evidence of patients with malunited fractures both demonstrate that DRFs led to fewer complication than more proximal fractures. Although they are rare, complications from DRFs in children include re-fracture and synostosis. Re-fracture can occur if immobilization is removed too quickly and is associated with worse motion and deformity in observational studies. Synostosis is usually associated with high energy trauma.
The Young Adult Population
Although DRFs are less frequent outside of the pediatric and elderly populations ( Fig. 1 ), they are still a relatively common injury across all age groups. Recent US data showed that DRFs are the third most common fracture in the 18- to 34-year-old population following metacarpal and phalangeal fractures. In the 35- to 49-year-old group, DRFs were second in frequency only to phalangeal fractures. Sports injuries and car accidents are the most common causes of DRFs in young adults less than 50 years of age.
Although gender differences exist in the pediatric and elderly DRF populations, men and women in the 19- to 49-year age group have identical fracture rates. However, analyzing the 19- to 65-year age group reveals a two-times higher DRF rate among woman than men. This is presumably a result of greater osteoporotic fracture incidence in women over 50. With respect to race, a majority (83%) of young adult DRFs occur in Caucasian individuals. However, this data point must be interpreted with caution. Differences in the likelihood of reporting to emergency departments influence the results.
The goal of DRF treatment is the same regardless of age: restore alignment using evidence-based treatments. In the young adult patient, the parameters for acceptable reduction are clear but the optimal method of fixation is inconclusive. Closed reduction and casting, percutaneous fixation, external fixation and open reduction and internal fixation (ORIF) are all treatment options for young adults with DRFs. Currently, there is a trend toward more operative interventions, as shown in Fig. 3 . In the young adult patient, the parameters for acceptable reduction are clear but the optimal method of fixation is inconclusive. Randomized, controlled trials are needed to determine the criteria for various treatments and evaluate the expected outcomes in this age group.
