Malaysian Healthy Ageing Society Management of Distal Radius - PowerPoint PPT Presentation

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Management of Distal Radius Fracture in the Elderly Patients Manohar Arumugam Dept of Orthopaedic Surgery Faculty of Medicine & Health Science University Putra Malaysia, Serdang 1st WORLD CONGRESS ON HEALTHY AGEING 19 th - 22 nd March 2012 KLCC Kuala Lumpur 2

Introduction • Frequently seen in patients with osteoporosis • Depending on the severity of the osteoporosis • Fractures can occur from simple activity such as getting up from bed to a more violent injury such as a fall 3

Epidemiology and Incidence • Distal radius fracture accounts for 15% of fractures in adults • 85% of women with DRF have low bone mineral density and • 51% of women with DRF have osteoporosis Hegeman JH, Oskam J, van der Palen J, Ten Duis HJ, Vierhout PAM.The distal radial fracture in elderly women and the bone mineral densityof the lumbar spine and hip. J Hand Surg Br. 2004;29(5):473 – 476. 4

Factors influencing stability of fractures in elderly • Distal radius fractures in elderly people tend to displace because they have osteoporotic bone • Osteoporosis weakens the metaphyseal bone by decreasing trabecular bone volumes • These fractures often show a large metaphyseal defect or void • This in turn increases fracture instability Sakai A, Oshige T, Zenke Y, Suzuki M, Yamanaka Y, Nakamura T. Association of bone mineral density with deformity of the distal radius in low-energy Colles ’ fractures in Japanese women above 50 years of age. J Hand Surg Am. 2008;33(6):820 – 826. 5

Factors influencing stability of fractures in elderly • A prospective study of 645 Colles ’ fractures treated conservatively also found that age was one of the most important predictors of displacement. Hove LM, Solheim E, Skjeie R, Sorensen FK. Prediction of secondary displacement in Colles ’ fracture. J Hand Surg Br. 1994;19(6):731 – 736. 6

Correlation of radiographic outcomes to functional outcomes in elderly patients • In the young population inadequate reduction means poor functional outcome • In an elderly population its different…numerous studies found that unacceptable post reduction Xray did not lead to poor function but again this is controversial 7

Treatment options Many factors must be taken into account These include: • fracture pattern • medical comorbidities • operative risk • functional demands • patient preference 8

Treatment options • Closed reduction and cast immobilization • Closed reduction and percutaneous pinning • External fixation • Open reduction and volar locking plate fixation 9

Closed reduction and cast immobilization • Initially fracture is reduced under sedation • And immobilized with a below elbow dorsal & volar slab • After the swelling has decreased • A below-elbow cast is applied • Xray of the wrist joint is taken to check reduction • If reduction is acceptable the wrist is immobilised for 4- 6 weeks 10

Criteria for acceptable fracture reduction • dorsal tilt does not exceed 20 deg • radial shortening is not more than 3 mm • intra-articular step off does not exceed 2 mm 11

Closed reduction and cast immobilization • If the reduction is not acceptable ,repeated manipulation should not be done • May result in Complex Regional Pain Syndrome type I • Active and passive finger motion is encouraged early. • After cast removal active motion of the wrist and grip strengthening is started 12

Closed reduction and cast immobilization • A cohort of 60 unstable distal radius fractures in patients with dementia or multiple medical comorbidities • Treated by closed reduction and cast immobilization • 53 healed in a malunited position • But functional results were satisfactory 13

Closed Reduction and Percutaneous Pinning • for reducible extra- articular and simple intra-articular DRFs • should not have metaphyseal comminution • good bone quality • a forearm splint is necessary post opt 14

External Fixation • for highly unstable and severely comminuted fractures • longitudinal traction indirectly pulls the fracture fragments out to length • applied for 6 weeks • Complications include pin-track infection iatrogenic lesion of the superficial radial nerve complex regional pain syndrome due to overdistraction 15

Open Reduction and Volar Locking Plate Fixation • fracture is reduced • reduction is maintained using an implant • allows early wrist mobilization 16

Case study • CNP • 60 years old Chinese lady • Date of injury :9/7/2007 • Motorcylist,knocked into a dog and skidded • Sustained: Close fracture distal end Lt radius • Medical problem: Diabetes mellitus 10 years 17

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Conclusion • No absolute consensus on the best method for treatment of distal radius fractures in the elderly • Controlled trials are required to evaluate the different methods of stabilization in elderly populations 32

In an active, healthy patient with an unstable fracture • an attempt at anatomic reduction and surgical fixation • is more likely to render good and functional results 33

In a low-functioning patient with • multiple medical comorbidities • conservative management is a safer option • acceptable clinical outcomes • even with malunion 34

Thank you 35