EVIDENCE-BASED MEDICINE
Distal Radius Fractures in the Elderly David M. Brogan, MD, MSc, David S. Ruch, MD THE PATIENT A 72-year-old, active, healthy woman fell onto her outstretched dominant right hand. The wrist was swollen and painful to move. Radiographs demonstrated a displaced intra-articular fracture of the distal radius. After hematoma block, manipulative reduction, and orthotic immobilization, radiographs demonstrate a residual radiocarpal articular stepoff of 2 mm with 10 dorsal angulation of the articular surface on the lateral radiograph. THE QUESTION Should an active, healthy, elderly patient undergo open reduction internal fixation with a volar locking plate or continue with nonsurgical treatment for a displaced fracture of the distal radius? CURRENT OPINION Osteoporosis places older patients at risk for fracture displacement after reduction and immobilization in a cast1,2 but most surgeons regard older patients as more accepting of and less affected by deformity, pursuing less-demanding activities, and at greater risk of adverse events with surgery. The best available evidence is regarded as inconclusive regarding recommendation for or against operative treatment of displaced fractures of the distal radius in patients aged 55 years or greater.3 Despite limited evidence that operative treatment outperforms nonsurgical treatment, older patients are increasingly undergoing operative treatment of distal radius fractures4 at a substantial cost to the health system.5 THE EVIDENCE A total of 87 patients with distal radius fractures treated with closed reduction and dorsal orthotic From the Department of Orthopaedic Surgery, Duke University, Durham, NC. Received for publication December 31, 2014; accepted in revised form January 2, 2015. D.S.R. is a consultant for and receives royalties from Acumed. Corresponding author: David S. Ruch, MD, Department of Orthopaedic Surgery, Duke University, 200 Trent Drive, Durham, NC 27710; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.01.001
immobilization and adequately aligned at the first office visit were randomized into 4 groups based on 2 criteria: type of immobilization (dorsal splint vs below-elbow cast) and formal therapy versus home exercises. There were no differences 6 months after injury. Nine to 13 years after injury, young (aged 19e59 y) and old (aged 60e78 y) patients were compared, excluding patients with a prior contralateral distal radius fracture. There was no significant difference in Green and O’Brien score. Twenty-eight percent of elderly patients were rated fair or poor. Radiographic signs of mild arthritis were noted in 12 of the 87 patients.6 Arora et al7 reviewed 114 unstable distal radius fractures (defined as a fracture that lost reduction between the emergency department and the first visit with the orthopedic surgeon) in patients older than age 70 years. Volar plate fixation was recommended to all 114 patients but 61 declined and were treated in a below-elbow cast for 6 weeks. An average of 51 months after volar plate fixation and 62 months after cast treatment, there were no differences in grip strength, active motion, Disabilities of the Arm, Shoulder, and Hand (DASH) score, Patient-Rated Wrist Evaluation (PRWE) score, or Green and O’Brien score between the 2 groups. Patients treated in a cast had less pain but more radiographic evidence of radiocarpal arthritis. Among patients with intraarticular fracture in the cast group, 53% developed mild arthritis and 17% developed moderate arthritis, compared with 43% and 7%, respectively, in the surgical group. A prominent ulnar head was noted in 77% of patients receiving nonsurgical but no patient was unhappy with the appearance of the wrist. The same group subsequently undertook a prospective, randomized, clinical trial of 73 patients aged 65 years and older with displaced and unstable lowenergy distal radius fractures.8 All patients were initially reduced and placed in an orthosis, and then subsequently randomized into 2 groups: nonsurgical treatment with a cast for 6 weeks or open reduction internal fixation with a volar locking plate. There were no differences in pain intensity or range of motion during one year of evaluation. The operative treatment group had better DASH and PRWE scores in the first
Ó 2015 ASSH
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Published by Elsevier, Inc. All rights reserved.
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DISTAL RADIUS FRACTURES IN THE ELDERLY
12 weeks of treatment but this did not persist after 3 months. Grip strength was better in the operative group at all times. There were more complications in the ORIF group (36% vs 14%); nearly one-third of operative patients had a secondary surgical procedure. A prominent ulnar head was noticeable in 78% of casted patients but no patient was unsatisfied with the appearance of the wrist. Among the 20 patients with articular fractures in the operative treatment group, 9 had mild arthritis and 4 had moderate arthritis within one year, compared with 12 and 7 patients, respectively, among the 25 with articular fractures treated nonsurgically.8 A retrospective study from Singapore reviewed 75 elderly patients (mean age, 74 y) with unstable distal radius fractures who were offered surgery, 35 of whom preferred cast immobilization for 6 weeks. Patients who chose surgery were younger (aged 71 vs 76 y) and had better motion and grip at 3 months, but not at 12 months after surgery. Radiographic measures were better with surgery but DASH and Green and O’Brien scores were no different at 1 year. Another retrospective review of 90 patients aged 65 years or older with distal radius fractures9 compared nonsurgical treatment with surgical intervention consisting of volar plate fixation or application of an external fixator. Criteria for nonsurgical management of the fracture included less than 10 residual dorsal angulation, less than 2 mm difference in ulnar variance compared with the uninjured wrist, less than 1 mm of articular stepoff, and no evidence of subluxation or widening of the distal radioulnar joint on anteroposterior or lateral radiographs. Surgery was offered to all patients with an unstable fracture pattern, defined by the authors as postreduction radiographs meeting 3 or more criteria of Lafontaine et al.10 Ultimately, the decision for operative or nonsurgical treatment was made by the patient after consultation with the treating physician. However, the authors did not specify how many patients treated with casting met the nonsurgical criteria or how many were offered surgery but declined. Instead, the analysis compared the outcome of all who were treated with casting and those treated with surgery. No difference was found between groups in DASH score or pain intensity at any evaluation time. Grip strength and radiographic parameters were significantly better in the operative group at one year but supination was significantly better in the nonsurgical group. Patients treated with surgery had lower rates of arthritis than those managed nonsurgically. A recent systematic review of outcomes and complications from treatment of distal radius fractures supported the findings that cast immobilization J Hand Surg Am.
results in worse radiographic parameters, fewer complications, and no clinically significant functional differences compared with surgical treatment.11 The review encompassed 2,039 articles, with subsequent inclusion of 21 papers, all focusing on outcomes in patient populations with a mean age of 60 years or greater. The authors compared cast immobilization with bridging and nonbridging external fixation, percutaneous pinning, and volar plate application. Cast immobilization resulted in an average dorsal tilt of 11 and ulnar variance of 3.6 mm. In comparison, volar tilt in the volar plating, nonbridging external fixation, and percutaneous pinning groups averaged 4 , 7 , and 4 . All of these demonstrated ulnar variance of less than 2 mm. SHORTCOMINGS OF THE EVIDENCE Current best evidence consists largely of retrospective reviews with nonrandomized treatment and short evaluation times. This leads to potential selection bias because patients with less severe injuries, greater comorbidities, or lower demands may choose nonsurgical treatment. Longer-term follow-up is necessary to assess the impact of malunion on progression of arthritis, as well as the functional impact of radiographic arthritis, but these concerns may be less critical in the elderly. The definition of an elderly patient is arbitrary and there is no stratification based on infirmity and activity level. Previous studies comparing operative and nonsurgical treatment in an elderly patient population used external fixation or percutaneous pinning rather than volar locked plating in the operative treatment group.12 DIRECTIONS FOR FUTURE RESEARCH Randomized, prospective trials comparing casting with volar plate fixation with adequate power to detect differences in the PRWE or DASH would help guide discussions between patients and surgeons. Longer-term evaluations would help clarify the prevalence, natural history, and symptoms of posttraumatic arthritis in the elderly and the influence of operative treatment. Articular fractures should be considered separately and with sufficiently long evaluation times to address the development and impact of posttraumatic arthritis. Healthy, active patients should be considered separately from infirm or low-demand individuals. OUR CURRENT CONCEPTS FOR THIS PATIENT We would advise our patient that the available evidence suggests that nonsurgical treatment is associated with greater visible deformity and that symptoms and disability improve for a year, but in the end they are no r
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DISTAL RADIUS FRACTURES IN THE ELDERLY
different on average than results with surgery. Extraarticular fractures without notable deformity, intraarticular fractures with minimal displacement, and fractures in low-demand patients may be effectively treated with reduction and casting.13 We find that most elderly patients choose nonsurgical treatment. Healthier, more active patients seem more likely to choose surgery. Patients who choose nonsurgical treatment are placed in an orthosis for 2 weeks to allow swelling to subside before changing to a below-elbow cast. The total period of immobilization is 6 weeks, at which point patients are given a removable wrist orthosis and taught stretching exercises.
5. Shauver MJ, Yin H, Banerjee M, Chung KC. Current and future national costs to Medicare for the treatment of distal radius fracture in the elderly. J Hand Surg Am. 2011;36(8):1282e1287. 6. Földhazy Z, Törnkvist H, Elmstedt E, Andersson G, Hagsten B, Ahrengart L. Long-term outcome of nonsurgically treated distal radius fractures. J Hand Surg Am. 2007;32(9):1374e1384. 7. Arora R, Gabl M, Gschwentner M, Deml C, Krappinger D, Lutz M. A comparative study of clinical and radiologic outcomes of unstable Colles type distal radius fractures in patients older than 70 years: nonoperative treatment versus volar locking plating. J Orthop Trauma. 2009;23(4):237e242. 8. Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011;93(23):2146e2153. 9. Egol KA, Walsh M, Romo-Cardoso S, Dorsky S. Distal radial fractures in the elderly: operative compared with nonoperative treatment. J Bone Joint Surg Am. 2010;92(9):1851e1857. 10. Lafontaine M, Hardy D, Delince PH. Stability assessment of distal radius fractures. Injury. 1989;20(4):208e210. 11. Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am. 2011;36(5): 824e835.e2. 12. Lichtman DM, Bindra RR, Boyer MI, et al. Treatment of distal radius fractures. J Am Acad Orthop Surg. 2010;18(3): 180e189. 13. Chauhan A, Merrell GA. Functional outcomes after nonsurgical treatment of distal radius fractures. J Hand Surg Am. 2012;37(12): 2600e2602.
REFERENCES 1. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am. 2004;29(6):1128e1138. 2. Koval K, Haidukewych GJ, Service B, Zirgibel BJ. Controversies in the management of distal radius fractures. J Am Acad Orthop Surg. 2014;22(9):566e575. 3. Lichtman DM, Bindra RR, Boyer MI, et al. Treatment of distal radius fractures. J Am Acad Orthop Surg. 2010;18(3):180e189. 4. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg Am. 2009;91(8):1868e1873.
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Distal Radius Fractures in the Elderly David M. Brogan, MD, MSc, David S. Ruch, MD THE PATIENT A 72-year-old, active, healthy woman fell onto her outstretched dominant right hand. The wrist was swollen and painful to move. Radiographs demonstrated a displaced intra-articular fracture of the distal radius. After hematoma block, manipulative reduction, and orthotic immobilization, radiographs demonstrate a residual radiocarpal articular stepoff of 2 mm with 10 dorsal angulation of the articular surface on the lateral radiograph. THE QUESTION Should an active, healthy, elderly patient undergo open reduction internal fixation with a volar locking plate or continue with nonsurgical treatment for a displaced fracture of the distal radius? CURRENT OPINION Osteoporosis places older patients at risk for fracture displacement after reduction and immobilization in a cast1,2 but most surgeons regard older patients as more accepting of and less affected by deformity, pursuing less-demanding activities, and at greater risk of adverse events with surgery. The best available evidence is regarded as inconclusive regarding recommendation for or against operative treatment of displaced fractures of the distal radius in patients aged 55 years or greater.3 Despite limited evidence that operative treatment outperforms nonsurgical treatment, older patients are increasingly undergoing operative treatment of distal radius fractures4 at a substantial cost to the health system.5 THE EVIDENCE A total of 87 patients with distal radius fractures treated with closed reduction and dorsal orthotic From the Department of Orthopaedic Surgery, Duke University, Durham, NC. Received for publication December 31, 2014; accepted in revised form January 2, 2015. D.S.R. is a consultant for and receives royalties from Acumed. Corresponding author: David S. Ruch, MD, Department of Orthopaedic Surgery, Duke University, 200 Trent Drive, Durham, NC 27710; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.01.001
immobilization and adequately aligned at the first office visit were randomized into 4 groups based on 2 criteria: type of immobilization (dorsal splint vs below-elbow cast) and formal therapy versus home exercises. There were no differences 6 months after injury. Nine to 13 years after injury, young (aged 19e59 y) and old (aged 60e78 y) patients were compared, excluding patients with a prior contralateral distal radius fracture. There was no significant difference in Green and O’Brien score. Twenty-eight percent of elderly patients were rated fair or poor. Radiographic signs of mild arthritis were noted in 12 of the 87 patients.6 Arora et al7 reviewed 114 unstable distal radius fractures (defined as a fracture that lost reduction between the emergency department and the first visit with the orthopedic surgeon) in patients older than age 70 years. Volar plate fixation was recommended to all 114 patients but 61 declined and were treated in a below-elbow cast for 6 weeks. An average of 51 months after volar plate fixation and 62 months after cast treatment, there were no differences in grip strength, active motion, Disabilities of the Arm, Shoulder, and Hand (DASH) score, Patient-Rated Wrist Evaluation (PRWE) score, or Green and O’Brien score between the 2 groups. Patients treated in a cast had less pain but more radiographic evidence of radiocarpal arthritis. Among patients with intraarticular fracture in the cast group, 53% developed mild arthritis and 17% developed moderate arthritis, compared with 43% and 7%, respectively, in the surgical group. A prominent ulnar head was noted in 77% of patients receiving nonsurgical but no patient was unhappy with the appearance of the wrist. The same group subsequently undertook a prospective, randomized, clinical trial of 73 patients aged 65 years and older with displaced and unstable lowenergy distal radius fractures.8 All patients were initially reduced and placed in an orthosis, and then subsequently randomized into 2 groups: nonsurgical treatment with a cast for 6 weeks or open reduction internal fixation with a volar locking plate. There were no differences in pain intensity or range of motion during one year of evaluation. The operative treatment group had better DASH and PRWE scores in the first
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
DISTAL RADIUS FRACTURES IN THE ELDERLY
12 weeks of treatment but this did not persist after 3 months. Grip strength was better in the operative group at all times. There were more complications in the ORIF group (36% vs 14%); nearly one-third of operative patients had a secondary surgical procedure. A prominent ulnar head was noticeable in 78% of casted patients but no patient was unsatisfied with the appearance of the wrist. Among the 20 patients with articular fractures in the operative treatment group, 9 had mild arthritis and 4 had moderate arthritis within one year, compared with 12 and 7 patients, respectively, among the 25 with articular fractures treated nonsurgically.8 A retrospective study from Singapore reviewed 75 elderly patients (mean age, 74 y) with unstable distal radius fractures who were offered surgery, 35 of whom preferred cast immobilization for 6 weeks. Patients who chose surgery were younger (aged 71 vs 76 y) and had better motion and grip at 3 months, but not at 12 months after surgery. Radiographic measures were better with surgery but DASH and Green and O’Brien scores were no different at 1 year. Another retrospective review of 90 patients aged 65 years or older with distal radius fractures9 compared nonsurgical treatment with surgical intervention consisting of volar plate fixation or application of an external fixator. Criteria for nonsurgical management of the fracture included less than 10 residual dorsal angulation, less than 2 mm difference in ulnar variance compared with the uninjured wrist, less than 1 mm of articular stepoff, and no evidence of subluxation or widening of the distal radioulnar joint on anteroposterior or lateral radiographs. Surgery was offered to all patients with an unstable fracture pattern, defined by the authors as postreduction radiographs meeting 3 or more criteria of Lafontaine et al.10 Ultimately, the decision for operative or nonsurgical treatment was made by the patient after consultation with the treating physician. However, the authors did not specify how many patients treated with casting met the nonsurgical criteria or how many were offered surgery but declined. Instead, the analysis compared the outcome of all who were treated with casting and those treated with surgery. No difference was found between groups in DASH score or pain intensity at any evaluation time. Grip strength and radiographic parameters were significantly better in the operative group at one year but supination was significantly better in the nonsurgical group. Patients treated with surgery had lower rates of arthritis than those managed nonsurgically. A recent systematic review of outcomes and complications from treatment of distal radius fractures supported the findings that cast immobilization J Hand Surg Am.
results in worse radiographic parameters, fewer complications, and no clinically significant functional differences compared with surgical treatment.11 The review encompassed 2,039 articles, with subsequent inclusion of 21 papers, all focusing on outcomes in patient populations with a mean age of 60 years or greater. The authors compared cast immobilization with bridging and nonbridging external fixation, percutaneous pinning, and volar plate application. Cast immobilization resulted in an average dorsal tilt of 11 and ulnar variance of 3.6 mm. In comparison, volar tilt in the volar plating, nonbridging external fixation, and percutaneous pinning groups averaged 4 , 7 , and 4 . All of these demonstrated ulnar variance of less than 2 mm. SHORTCOMINGS OF THE EVIDENCE Current best evidence consists largely of retrospective reviews with nonrandomized treatment and short evaluation times. This leads to potential selection bias because patients with less severe injuries, greater comorbidities, or lower demands may choose nonsurgical treatment. Longer-term follow-up is necessary to assess the impact of malunion on progression of arthritis, as well as the functional impact of radiographic arthritis, but these concerns may be less critical in the elderly. The definition of an elderly patient is arbitrary and there is no stratification based on infirmity and activity level. Previous studies comparing operative and nonsurgical treatment in an elderly patient population used external fixation or percutaneous pinning rather than volar locked plating in the operative treatment group.12 DIRECTIONS FOR FUTURE RESEARCH Randomized, prospective trials comparing casting with volar plate fixation with adequate power to detect differences in the PRWE or DASH would help guide discussions between patients and surgeons. Longer-term evaluations would help clarify the prevalence, natural history, and symptoms of posttraumatic arthritis in the elderly and the influence of operative treatment. Articular fractures should be considered separately and with sufficiently long evaluation times to address the development and impact of posttraumatic arthritis. Healthy, active patients should be considered separately from infirm or low-demand individuals. OUR CURRENT CONCEPTS FOR THIS PATIENT We would advise our patient that the available evidence suggests that nonsurgical treatment is associated with greater visible deformity and that symptoms and disability improve for a year, but in the end they are no r
Vol. -, - 2015
DISTAL RADIUS FRACTURES IN THE ELDERLY
different on average than results with surgery. Extraarticular fractures without notable deformity, intraarticular fractures with minimal displacement, and fractures in low-demand patients may be effectively treated with reduction and casting.13 We find that most elderly patients choose nonsurgical treatment. Healthier, more active patients seem more likely to choose surgery. Patients who choose nonsurgical treatment are placed in an orthosis for 2 weeks to allow swelling to subside before changing to a below-elbow cast. The total period of immobilization is 6 weeks, at which point patients are given a removable wrist orthosis and taught stretching exercises.
5. Shauver MJ, Yin H, Banerjee M, Chung KC. Current and future national costs to Medicare for the treatment of distal radius fracture in the elderly. J Hand Surg Am. 2011;36(8):1282e1287. 6. Földhazy Z, Törnkvist H, Elmstedt E, Andersson G, Hagsten B, Ahrengart L. Long-term outcome of nonsurgically treated distal radius fractures. J Hand Surg Am. 2007;32(9):1374e1384. 7. Arora R, Gabl M, Gschwentner M, Deml C, Krappinger D, Lutz M. A comparative study of clinical and radiologic outcomes of unstable Colles type distal radius fractures in patients older than 70 years: nonoperative treatment versus volar locking plating. J Orthop Trauma. 2009;23(4):237e242. 8. Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011;93(23):2146e2153. 9. Egol KA, Walsh M, Romo-Cardoso S, Dorsky S. Distal radial fractures in the elderly: operative compared with nonoperative treatment. J Bone Joint Surg Am. 2010;92(9):1851e1857. 10. Lafontaine M, Hardy D, Delince PH. Stability assessment of distal radius fractures. Injury. 1989;20(4):208e210. 11. Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am. 2011;36(5): 824e835.e2. 12. Lichtman DM, Bindra RR, Boyer MI, et al. Treatment of distal radius fractures. J Am Acad Orthop Surg. 2010;18(3): 180e189. 13. Chauhan A, Merrell GA. Functional outcomes after nonsurgical treatment of distal radius fractures. J Hand Surg Am. 2012;37(12): 2600e2602.
REFERENCES 1. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am. 2004;29(6):1128e1138. 2. Koval K, Haidukewych GJ, Service B, Zirgibel BJ. Controversies in the management of distal radius fractures. J Am Acad Orthop Surg. 2014;22(9):566e575. 3. Lichtman DM, Bindra RR, Boyer MI, et al. Treatment of distal radius fractures. J Am Acad Orthop Surg. 2010;18(3):180e189. 4. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg Am. 2009;91(8):1868e1873.
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