Distal radius fractures in older versus younger patients
Fractures of the distal radius are among the most common injuries seen in an adult orthopedic practice and account for about one-sixth of fractures treated in emergency departments. Most result from a fall on an outstretched hand with the wrist in extension. The fractures occur primarily in young adults and people over age 65, and can vary considerably between the two groups.
In young people, for example, distal radius fractures are often caused by high-energy trauma that involves various combinations of bending, compression, impaction and shearing. These injuries may result in fractures with metaphyseal comminution, and can, in some cases, cause extensive damage to the joint surface, fragmentation of the metaphysis, and injury to the ulna and triangular fibrocartilage. In older adults, a large majority of distal radius fractures result from lower energy injuries such as ground-level falls, often leading to more typical extra-articular, dorsally angulated or displaced fractures.
The various fracture patterns and displacement of the fragments can provide a sense of fracture stability; closed reduction and immobilization are then used to help determine treatment. Radiographs are compared before and after reduction to assess for acceptable alignment in the cast or splint, and additional imaging, such as CT, may be used to look for other problems, such as carpal bone injury.
Although surgery is often considered for displaced and unstable distal radius fractures, optimal treatment depends on several factors, according to David G. Dennison, M.D., a hand and wrist surgeon at Mayo Clinic's campus in Rochester, Minnesota.
"The goal of treatment is to restore the previous level of function, but the appropriate treatment may vary, depending upon the patient's age and activity level, existing medical conditions, bone quality, and amount of displacement," he says. "All of these factors need to be carefully considered and individualized in order to achieve the best functional outcome while also minimizing risk. In general, less invasive treatments that achieve satisfactory alignment and stable reduction of the bone fragments can lead to good outcomes."
For older, less active patients and adults with low or moderate demands, closed reduction and casting are almost always preferred, especially for mild shortening of 2 to 3 millimeters (mm) and articular displacement of less than 2 mm, Dr. Dennison says.
"You have to consider a patient's activity level. With young patients, we tend to be more aggressive in achieving a more anatomic reduction of the fracture and the joint surface. Many older adults are now remaining more physically active, and they also may benefit from surgical treatment of a displaced or unstable fracture. On the other hand, some older and low-demand patients may accept a mild or moderate deformity with acceptable function following fracture healing. Surgical treatment is considered if closed reduction with splinting does not result in acceptable alignment."
Volar plate fixation
One common method of treating extra-articular fractures is to obtain an open reduction and then apply external fixation using a volar locking plate. Although volar plates are not applicable to all fractures, the literature increasingly supports volar plate fixation with distal locking screws or pegs for older patients, including those with osteoporosis.
The volar approach commonly used today involves a longitudinal incision over the flexor carpi radialis tendon and takes advantage of an anatomic recess at the pronator quadratus fossa for plate placement. In intra-articular fractures, the exposure may include release of the brachioradialis tendon to expose the fracture site and allow access to the subchondral bone and to release the deforming force from the brachioradialis. The process then continues with reduction of the volar lunate facet, the dorsal lunate facet and the radial styloid. If needed, a dorsal arthrotomy or arthroscopy is used to obtain reduction of the joint surface.
Volar plate fixation has proved superior to external fixation in terms of recovery and minor complications, but studies have not shown that it improves long-term overall function. It also can result in complications that require revision surgeries, such as tendon rupture. Other limitations of volar plating include the inability to visualize the joint surface or interosseous ligament injuries and difficulty in stabilizing distal and ulnar-sided radius fracture fragments.
"Mayo Clinic has extensive experience with the volar approach, and we are leaning toward internal fixation more than in the past because we have better locking plates that can stabilize the fracture from the palmar side of the wrist," Dr. Dennison says. "Older dorsal implants worked well to stabilize the fracture but had a high rate of complications, and although the volar plates are a better implant, we continue to see some complications with surgical treatment. Still, if patients are reasonably healthy and active and the fracture is amenable to this type of fixation, we will offer surgery as most patients will have a good outcome."
In general, there is no real consensus on the best treatment of distal radius fractures in older patients because studies indicate there is little difference in long-term functional outcomes between surgical and nonsurgical management. A systematic review published in The Journal of Hand Surgery in 2011 compared five techniques commonly used to treat distal radius fractures in adults over 60:
- The volar locking plate system
- Nonbridging external fixation
- Bridging external fixation
- Wire fixation
- Cast immobilization
The results showed that although radiographic outcomes were worse with cast immobilization, functional outcomes were no different from those of surgically treated patients.
"There are a few general themes in the literature," Dr. Dennison says. "One is that some older patients can manage quite well even with moderate or severe deformity. Another theme is that for older adults, if alignment is not too far off, outcomes with cast immobilization rival operative outcomes but with a lower rate of complications. The third is that younger patients and active adults likely do better with anatomical alignment."
For more information
Diaz-Garcia RJ, et al. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. The Journal of Hand Surgery. 2011;36:824.