The 75-Year-Old Distal Radius Fracture Do You Want a Pair of Glasses? Read the Literature! Nonoperative Treatment, They Do Fine Mani Kahn MD
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Goals of Care • Improve pain • Restore function • Minimize complications
Pain Study VAS Arora 2011 No Difference Egol 2010 No Difference Arora 2009 ORIF>Nonop (p=0.03)
Function Study DASH/Mayo Grip Strength ROM Chan 2014 No Difference ORIF Arora 2011 Early ORIF No Difference Difference Aktekin 2010 No Difference No Difference WE, UD Egol 2010 No Difference ORIF Early Difference WE Wong 2010 No Difference No Difference No Difference Arora 2009 No Difference No Difference No Difference
Function Despite better grip strength, no difference in the ability to perform activities of daily living Arora R et al 2011 Continued improvement in pain, grip strength and ROM for up to 4 years Brogren E et al 2011
Meta-analysis 8 studies Surgical group 440 patients Control Group 449 patients Pain DASH Grip Strength ROM No Difference No Difference No Difference Control Group Superior WF/RD Ju JH et al 2015
What about the “active” older patient? Malunion does not affect QuickDASH, VAS function, strength and wrist motion Nelson et al 2014
Intra-articular fractures ORCHID Trial @ 1 yr ORIF… -SF36 no improvement -DASH Marginal improvement Bartl et al 2014
Operative Complications More common and more severe • 12% Infection rate • 31% Revision Rate Lutz K et al 2014
Radiographic and Cosmetic Outcomes • Significant improvement in radiographic indices with operative treatment • Nonoperative malunion rate 89-100%
Patient Satisfaction Study Patient Satisfaction Arora 2011 No Difference Wong 2010 No Difference
Cost • $170 Million annually • ORIF is 3x more expensive
Goals of Care • Improve pain • Restore function • Minimize Complications • Cosmetic outcome?
In the elderly… • Unsatisfactory radiographic outcome ≠ unsatisfactory functional outcome
• “The limb will at some remote period again enjoy perfect freedom in all its motion and be completely exempt from pain: the deformity, however, will remain undiminished through life.” Abraham Colles, 1814 –
References Chung, KC et al. Variations in the Use of Internal Fixation for Distal Radial Fracture in the United States Medicare Population J Bone Joint Surg Am. • 2011;93:2154-62 Colles A. On the fracture of the carpal extremity of the radius. Edin Med Surg J 1814;10:182–186. • Porter M, Stockley I. Fractures of the distal radius. Intermediate and end results in relation to radiologic parameters. Clin Orthop Relat Res • 1987;220:241–252. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg • 1994;19A:325–340. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg 1986;68A:647–659. • Ju JH et al. Comparison of treatment outcomes between nonsurgical and surgical treatment of distal radius fracture in elderly: a systematic review • and meta-analysis Langenbecks Arch Surg (2015) 400:767–779 Lutz K, Yeoh KM, MacDermid JC, Symonette C, Grewal R (2014) Complications associated with operative versus nonsurgical treatment of distal radius • fractures in patients aged 65 years and older. J Hand Surg Am 39:1280–1286 Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M (2011) 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 93:2146–2153 Chan YH, Foo TL, Yeo CJ, Chew WY (2014) Comparison between cast immobilization versus volar locking plate fixation of distal radius fractures in • active elderly patients, the Asian perspective. Hand Surg 19:19–23 Arora R, Gabl M, Gschwentner M, Deml C, Krappinger D, Lutz M (2009) 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 23:237–242 Egol KA, Walsh M, Romo-Cardoso S, Dorsky S, Paksima N (2010) Distal radial fractures in the elderly: operative compared with non- operative • treatment. J Bone Joint Surg Am 92:1851–185 Aktekin CN, Altay M, Gursoy Z, Aktekin LA, Ozturk AM, Tabak AY (2010) Comparison between external fixation and cast treat- ment in the • management of distal radius fractures in patients aged 65 years and older. J Hand Surg Am 35:736–742 Wong TC, Chiu Y, Tsang WL, Leung WY, Yam SK, Yeung SH (2010) Casting versus percutaneous pinning for extra-articular frac- tures of the distal • radius in an elderly Chinese population: a pro- spective randomised controlled trial. J Hand Surg Eur Vol 35:202– 208 Brogren E, Hofer M, Petranek M, Dahlin LB, Atroshi I: Fractures of the distal radius in women aged 50 to 75 years: Natural course of patient-reported • outcome, wrist motion and grip strength between 1 year and 2-4 years after fracture. J Hand Surg Eur Vol 2011;36(7):568-576. Nelson et al The Impact of Patient Activity Level on Wrist Disability After Distal Radius Malunion in Older Adults J Orthop Trauma Volume 29, • Number 4, April 2015 Bartle et al The Treatment of Displaced Intra-articular Distal Radius Fractures in Elderly Patients Deutsches Ä rzteblatt International | Dtsch Arztebl Int • 2014; 111: 779–87
• ORIF: 4.6% to 42.1%
Scope of the problem • Second most common fragility fracture • One in Ten 65 year old women will suffer DRF in remaining lifetime
Treatment Controversy AAOS Clinical Practice Guidelines “We are unable to recommend for or against operative treatment for patients over age 55 with distal radius fractures.”
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