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C OPYRIGHT 2010
BY

T HE J OURNAL

OF

B ONE

AND J OINT

S URGERY, I NCORPORATED

A commentary by Lisa Cannada, MD, is available at www.jbjs.org/commentary and as supplemental material to the online version of this article.

Distal Radial Fractures in the Elderly: Operative Compared with Nonoperative Treatment
By K.A. Egol, MD, M. Walsh, PhD, S. Romo-Cardoso, MD, Seth Dorsky, BS, and N. Paksima, DO
Investigation performed at New York University Hospital for Joint Diseases, New York, and Jamaica Hospital Medical Center, Jamaica, New York

Background: There is much debate regarding the optimal treatment of displaced, unstable distal radial fractures in the elderly. The purpose of this retrospective review was to compare outcomes for elderly patients with a displaced distal radial fracture who were treated with or without surgical intervention. Methods: This case-control study examined ninety patients over the age of sixty-ve who were treated with or without surgery for a displaced distal radial fracture. All fractures were initially treated with closed reduction and splinting. Patients who failed an acceptable closed reduction were offered surgical intervention. Patients who did not undergo surgery were treated until healing with cast immobilization. Patients who underwent surgery were treated with either plate-and-screw xation or external xation. Baseline radiographs and functional scores were obtained prior to treatment. Follow-up was conducted at two, six, twelve, twenty-four, and fty-two weeks. Clinical and radiographic follow-up was completed at each visit, while functional scores were obtained at the twelve, twenty-four, and fty-two-week follow-up evaluations. Outcomes at xed time points were compared between groups with standard statistical methods. Results: Forty-six patients with a mean age of seventy-six years were treated nonoperatively, and forty-four patients with a mean age of seventy-three years were treated operatively. Other than age, there was no difference with respect to baseline demographics between the cohorts. At twenty-four weeks, patients who underwent surgery had better wrist extension (p = 0.04) than those who had not had surgery. At one year, this difference was not seen. No difference in functional status based on the Disabilities of the Arm, Shoulder and Hand scores and pain scores at any of the follow-up points was seen between the groups. Grip strength at one year was signicantly better in the operative group. Radiographic outcome was superior for the patients in the operative group at each follow-up interval. There was no difference between the groups with regard to complications. Conclusions: Our ndings suggest that minor limitations in the range of wrist motion and diminished grip strength, as seen with nonoperative care, do not seem to limit functional recovery at one year. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

controversial aspect of distal radial fracture treatment deals with the optimal management of these injuries in the elderly. Some authors have recommended anatomic restoration of displaced, unstable distal radial fractures in young patients as the best way to achieve optimal results1-6. The value of closed reduction of displaced distal radial fractures in elderly patients has been questioned if nonoperative treatment is chosen7. Nevertheless, very good clinical outcomes

have been documented in elderly patients with unstable fracture patterns who were treated nonoperatively even if the fracture was allowed to heal with malalignment of the distal end of the radius8. It has been demonstrated that malalignment does not necessarily correlate with functional outcome following distal radial fractures in elderly patients9. Despite this observation, the rate of operative treatment of distal radial fractures in the elderly has increased over the last decade10. Our

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benets in excess of $10,000 or a commitment or agreement to provide such benets from commercial entities (Stryker, Synthes, and Biomet).

J Bone Joint Surg Am. 2010;92:1851-7

doi:10.2106/JBJS.I.00968

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null hypothesis was that there would be no difference in outcome in patients sixty-ve years of age or older who sustained an unstable distal radial fracture and were treated either operatively or nonoperatively. The purposes of this retrospective study were to compare two cohorts of elderly patients with a distal radial fracture who were managed operatively or nonoperatively and to evaluate each method for clinical, radiographic, and functional outcome. Materials and Methods etween October 2004 and October 2008, 600 patients who sustained a distal radial fracture presented to our institution and were enrolled into a database. One-hundred and ftysix patients (26% of the entire cohort) who were more than sixty-ve years old were identied in the database and extracted for this study. Eighty-two patients were treated operatively and seventy-four, nonoperatively. Three patients with a stable, nondisplaced fracture were treated nonoperatively with splinting and/or casting and were not included in this analysis. Thirty-two patients in the operative group and seventeen in the nonoperative group missed their one-year follow-up appointments and were excluded. Six patients treated with surgery and eight treated nonoperatively had incomplete radiographic or clinical follow-up data. The remaining ninety patients (58%) with a displaced fracture are included in this report. Initially, all displaced fractures underwent closed reduction and application of a sugar-tong splint. Informed consent was obtained, and trained interviewers obtained baseline demographic data, injury information, and a baseline functional score on the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire11. The DASH is a thirty-item validated outcome questionnaire that measures upper extremity disability on the basis of physical function and symptoms. A complete history and physical examination were performed, and open wounds and neurovascular status were recorded. A series of standard radiographs was made at the time of the initial injury and included posteroanterior, lateral, and oblique views of the affected and contralateral wrists. Comparison radiographs of the contralateral wrist (assuming that it had no previous pathology) were made to assess normal alignment parameters on an individual basis, where ulnar variance is a key, but not the sole, radiographic criterion used to guide treatment and assess adequacy of reduction. Fractures were classied according to the system of the Orthopaedic Trauma Association (OTA) 12. Open wounds were classied according to the system of Gustilo et al.13,14. Measurements of radial inclination, height, tilt, ulnar variance, and articular step-off were recorded from each radiograph. At one year, radiographs were assessed for the presence of posttraumatic arthritis. Patients who met agreed-on criteria for closed treatment on the basis of radiographic, injury, and demographic parameters3,15 were discharged to follow-up in the outpatient setting within one week of presentation and were reexamined clinically and radiographically to assess maintenance of the reduction. These criteria included <10 of residual dorsal angulation (from neutral), a <2-mm difference in ulnar

variance compared with the contralateral side, 1 mm of articular step-off, no dorsal or volar subluxation of the distal radioulnar joint on the true lateral radiograph, and no widening of the distal radioulnar joint on the posteroanterior radiograph. These patients were then reexamined clinically and radiographically on a weekly basis for the following three weeks to assess the maintenance of reduction. At the completion of the initial follow-up visits, the patients were seen at six, twelve, twenty-four, and fty-two weeks. Measurements of all parameters were recorded. Surgery was indicated in patients with an open fracture or those with an inherently unstable fracture pattern (generally dened by at least three of the following criteria as discussed by Lafontaine et al.15: initial dorsal angulation of >20, initial shortening of >5 mm, >50% dorsal comminution, an intraarticular fracture, or an age of more than sixty years with an associated ulnar fracture), a shear fracture, or a fracturedislocation of the wrist. In patients who lost reduction and were considered to have met the radiographic criteria for surgery, a discussion of options was held between the surgeon and the patient. A decision for the best care of the patient was arrived at by mutual consent. Forty-six patients who did not undergo surgery were treated to completion with casting. Patients who underwent surgery were treated with either a volar locked plate or bridging external xation with supplemental Kirschner wire xation (usually two or three wires). The patients treated with external xation (EBI; Biomet, Warsaw, Indiana) underwent closed reduction and had two 3.0-mm pins inserted into the base of the second metacarpal and two 3.3-mm pins inserted into the distal third of the radius. All pins were placed in an open manner. Open reduction and plate application was accomplished through an extended exor carpi radialis approach16,17. All fractures were reduced open and were stabilized with a locked precontoured volar plate (Hand Innovations, Miami, Florida, or Stryker, Mahwah, New Jersey). Operatively treated patients were followed at two, six, twelve, twenty-four, and fty-two weeks. Postoperatively, all patients had a volar plaster splint applied. Patients treated with external xation were started on nger and forearm range-ofmotion exercises and were seen at the described follow-up points for radiographic and clinical reassessment. The external xator remained in place for six weeks and was then removed in the ofce. Those treated with a plate had a removable socalled cock-up wrist splint applied for comfort and were allowed free movement of their wrists and ngers. All patients were seen by their treating surgeon, and all data were collected by an independent, trained researcher at each follow-up visit. All patients participated in a formal outpatient therapy program, which emphasized active and passive range of nger motion, wrist motion (if able), and forearm motion. The number of therapy sessions attended was recorded at each follow-up visit. Follow-up examinations conducted at three, six, and twelve months included measurements of wrist and nger range of motion (made by an independent, trained researcher), grip strength measured with a dynamometer, and

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functional outcome measured with use of the DASH questionnaire11. Grip strength measured on the uninjured side at three months postoperatively was utilized as a control for comparison. Pain was rated with use of a 10-point visual analog scale, with 0 indicating no pain and 10, severe pain. Radiographic outcome with regard to fracture union, loss of reduction, and development of arthritis was assessed at each visit. Measurements of radial inclination, radial height, tilt, ulnar variance, and articular step-off were made on each radiograph by a trained research associate under the direction of the treating surgeon. Arthritic change or its advancement was noted if present, with use of the system described by Knirk and Jupiter18, at the three, six, and twelve-month examinations. Statistical Analysis Differences in demographic characteristics were assessed with use of chi-square tests for categorical variables (sex, hand dominance, fracture pattern, income level, and comorbidities) and the Student t test for continuous variables (age). Differences in range of motion and radiographic measurements were assessed with use of t tests. Differences in follow-up DASH scores were assessed with use of linear regression in order to control for baseline scores. A p value of 0.05 was considered signicant. Source of Funding No outside source of funding was utilized for this research project. Results inety patients met the inclusion criteria and form the basis of this report. Forty-six patients with a mean age of seventy-six years were treated nonoperatively, and forty-four patients with a mean age of seventy-three years were treated surgically. No other sociodemographic differences (sex, hand dominance, fracture pattern, socioeconomic status, and number of preexisting medical conditions, such as cardiovascular disease, any endocrine disease, any pulmonary disease, or malignancy) between the two groups were seen (Table I). No differences in baseline DASH scores were seen between the groups, indicating similar preinjury functional status. The clinical and functional results are presented in Table II. At three months, no differences were seen in range of wrist motion between the groups. At six months, patients treated nonoperatively had better wrist extension only (59 compared with 50; p = 0.04), while no differences in wrist exion and radial or ulnar deviation were seen. At one year, those who had undergone operative treatment had signicantly better grip strength, when controlling for the uninjured side (39.0 lb [17.7 kg] compared with 27.9 lb [12.7 kg]). Modestly better supination was seen in nonoperatively treated patients compared with those who were treated operatively (Table II). Pain scores were low throughout follow-up, with no differences in reported pain between the two groups at any time point (Table II). Furthermore, no differences in functional status were detected between the groups on the basis of the

TABLE I Characteristics of Patients Sixty-ve Years or Older by Operative Status Nonoperative Group (N = 46) 76 7.0 25 5.0 40 (87) 23 (50) 4 (9) 19 (41) 16 21.1 Operative Group (N = 44) 73 6.2 25 3.9 36 (82) 20 (45) 5 (11) 19 (44) 12 13.8

Characteristic Age (yr) Body mass index (kg/m2) Female patients OTA classication A B C Baseline DASH score

P Value* 0.03 NS NS NS NS NS NS

*NS = not signicant. The values are given as the mean and the standard deviation. DASH = Disabilities of the Arm, Shoulder and Hand. The values are given as the number of patients with the percentage in parentheses. OTA = Orthopaedic Trauma Association.

DASH scores at three months, six months, or one year (Table II). Using a post hoc power analysis, we had 80% power to detect a difference of 15 points in the DASH score at each of the follow-up periods. Fifteen points on the DASH instrument corresponds to what is clinically meaningful in terms of a demonstrative functional difference. Therefore, we can conclude that the lack of differences in DASH scores at three, six, and twelve months was real and not due to insufcient study power. Surgical intervention was able to maintain accepted fracture reduction parameters to a much greater extent than cast immobilization, and radiographic outcomes were superior with surgical intervention. At each follow-up interval, radial inclination and radial length were better in the operatively treated group, and, at one year, all radiographic parameters were signicantly better in the operative group compared with the nonoperative group (Table II). Also at one year, a greater number of patients in the nonoperative group (thirty-two; 70%) had grade-1 arthritic change compared with those in the operative group (nine; 20%) (Table III). Complications are reported in Table IV. In the operatively treated group, three patients developed symptoms of median nerve compression by six weeks postoperatively. In one of the three patients, the symptoms resolved without intervention. One patient refused further intervention, and one patient who had persistent symptoms at six months underwent a carpal tunnel release. One patient developed symptoms of de Quervain tenosynovitis, which was successfully treated with multiple corticosteroid injections. A total of four patients underwent additional surgery. A sixty-eight-year- old man who had undergone open reduction and internal xation with a volar locked plate underwent hardware removal of a prominent plate after examination at three months revealed clicking and

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TABLE II Nonoperative Compared with Operative Treatment in the Elderly Outcomes* 3 months Pain score Extension (deg) Flexion (deg) Supination (deg) Pronation (deg) Ulnar deviation (deg) Radial deviation (deg) Grip strength (lb [kg]) Volar tilt (deg) Radial inclination (deg) Radial length (mm) Ulnar variance (mm) DASH 6 months Pain score Extension (deg) Flexion (deg) Supination (deg) Pronation (deg) Ulnar deviation (deg) Radial deviation (deg) Grip strength (lb [kg]) Volar tilt (deg) Radial inclination (deg) Radial length (mm) Ulnar variance (mm) DASH 12 months Pain score Extension (deg) Flexion (deg) Supination (deg) Pronation (deg) Ulnar deviation (deg) Radial deviation (deg) Grip strength (lb [kg]) Volar tilt (deg) Radial inclination (deg) Radial length (mm) Ulnar variance (mm) DASH 1.5 2.1 54.6 14.9 51.8 11.1 83.9 3.0 84.4 3.8 30.3 7.1 22.9 13.4 27.9 14.3 (12.7 6.5) 5.8 10.4 18.0 4.0 8.7 1.6 2.8 1.8 12.1 29.6 1.2 1.7 54.8 18.7 47.8 13.1 80.6 8.1 82.9 6.8 29.9 8.8 18.7 7.9 39.0 16.1 (17.7 7.3) 6.2 9.2 22.3 4.7 10.6 2.5 1.5 2.2 10.0 20.3 NS NS NS 0.03 NS NS NS 0.005 <0.0001 0.0001 0.0008 0.007 NS 1.8 2.2 58.7 17.1 49.0 15.8 76.1 14.4 80.6 11.6 21.9 9.2 18.7 8.6 24.0 15.7 (10.9 7.1) 2.3 13.7 16.7 4.9 7.6 3.0 2.4 2.7 17.4 28.0 2.2 2.4 50.2 16.1 48.9 14.5 80.0 10.5 80.7 12.8 25.5 9.0 17.3 7.2 27.2 17.2 (12.3 7.8) 6.8 11.2 21.1 3.5 9.8 2.2 2.3 4.1 18.1 23.3 NS 0.04 NS NS NS NS NS NS 0.008 NS 0.003 NS NS 2.4 2.6 41.7 15.9 42.1 15.4 70.6 18.0 79.8 8.9 22.3 12.1 14.4 7.2 17.2 13.7 (7.8 6.2) 1.1 13.1 17.0 6.1 7.9 3.1 2.5 2.5 27.2 27.8 2.0 2.2 46.2 18.2 40.9 13.8 71.6 20.4 83.2 8.7 20.6 9.2 17.1 9.9 30.5 46.2 (13.8 20.9) 3.8 7.0 20.3 3.8 9.8 2.7 1.4 2.6 21.3 25.8 NS NS NS NS NS NS NS NS 0.04 0.005 0.004 NS NS Nonoperative Group Operative Group P Value

*DASH = Disabilities of the Arm, Shoulder and Hand questionnaire. The values are given as the mean and the standard deviation. NS = not signicant.

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TABLE III Comparison of Osteoarthritis Grade in Nonoperative and Operative Groups at Three, Six, and TwelveMonth Follow-up Evaluations Nonoperative Group (N = 46) Operative Group (N = 44)

18

Osteoarthritis Grade* 3 months 0 1 2 3 6 months 0 1 2 3 12 months 0 1 2 3

P Value 0.71

28 14 4 0 19 20 7 0 9 32 5 0

30 12 2 0 0.09 29 10 3 2 <0.001 29 9 4 2

reduction and internal xation of the fracture with a volar plate. In the nonoperatively treated group, three patients reported symptoms of carpal tunnel syndrome at various time points following the fracture. In two patients, the symptoms resolved by three months. One patient, an eighty-three-yearold woman, had persistent symptoms but did not desire surgical intervention. A seventy-ve-year-old woman developed de Quervain tenosynovitis at six weeks, and the symptoms persisted to one year. She was treated with bracing and multiple corticosteroid injections. This patient also developed a middledigit trigger nger at one year. None of the nonoperatively treated patients underwent surgical treatment for complications related to the distal radial fracture. Discussion e found improved grip strength and superior radiographic results with operative treatment of unstable, displaced distal radial fractures compared with nonoperative treatment in patients greater than sixty-ve years of age. Despite these differences, neither functional status, as measured by the DASH, nor reported pain were signicantly different between the two groups of elderly patients. When deciding on a treatment strategy for a particular fracture type, the treating surgeon must assess the risks, benets, and alternatives of each treatment modality and decide what benets to the patient can be afforded at what potential risk. A number of clinical papers have supported the idea that anatomic restoration of the distal end of the radius is essential to gain superior results5,18-20. Many of the studies are retrospective and uncontrolled. Hattori et al.19 retrospectively reported on twenty-eight patients, all more than seventy years old, who sustained a type-C fracture and were treated with anatomic restoration of the joint. All had undergone arthroscopic joint reduction, but xation methods varied from Kirschner wires to external xation to plates and screws. Nineteen of the twenty-eight patients had a good or excellent result on the basis of the system of Green and OBrien and the DASH score for selected patients (only fourteen had a DASH score) but nine had a fair or poor outcome. In a small, prospective, randomized, controlled trial of thirty patients over the age of sixty years with unstable distal radial fractures treated either with closed reduction and casting or with external xation with Kirschner wires, no difference was found between the groups with respect to outcome20. The issue of wrist deformity as a predictor of outcome in elderly patients with a distal radial fracture has been well documented in the literature. Jaremko et al.21 reviewed seventyfour patients over the age of fty years who had sustained a displaced distal radial fracture. At six months, the patients were contacted, and DASH scores, Short Form-12 scores, and patient satisfaction ratings were obtained. The authors found no signicant differences in patient-reported outcomes between patients whose healed fractures were within the accepted radiographic parameters that had been established and those whose healed fractures were outside the parameters. Wong

*A grade of 0 = none, 1 = slight narrowing, 2 = marked joint space narrowing and osteophyte formation, and 3 = bone on bone, osteophyte formation, and cyst formation.

TABLE IV Complications Nonoperative Group* 3 (7) 1 (2) 0 0 0 0 NA Operative Group* 3 (7) 1 (2) 0 1 (2) 1 (2) 0 1 (2)

Complication Carpal tunnel symptoms Tendinitis Infection Severe nger stiffness Severe ulnar-sided wrist pain Tendon rupture Prominent hardware

*The values are given as the number of patients with the percentage in parentheses. NA = not applicable.

exor tendon tenosynovitis. A sixty-ve-year-old woman underwent capsulectomy and tenosynovectomy of multiple digits for excessive stiffness following external xation at six months postoperatively. A seventy-seven-year-old woman underwent a distal ulnar resection at six months for persistent ulnar-sided wrist pain. As previously mentioned, an eighty-year-old man underwent carpal tunnel release at six months following open

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et al. performed a randomized controlled trial of closed treatment with casting alone compared with pinning and casting of distal radial fractures in sixty elderly patients22. Those authors also found superior radiographic results with surgery. This nding, however, did not correlate with function. Similar to those reports, our results did not show a correlation between malunion and poor functional results. Grewal et al.9 performed a prospective observational study of 216 patients who had sustained an extra-articular distal radial fracture and were pooled from nine treating physicians. Seventy-seven percent of the patients over sixty-ve years of age were treated nonoperatively compared with 56% of the younger patients. These patients were followed for a year after the injury. Radiographic evaluation was performed with standard wrist series, and functional scores were obtained with use of the DASH and Patient-Rated Wrist Evaluation questionnaires. The mean age of this cohort was 55.2 years, with seventy-three patients who were older than sixty-ve years. Fifty-eight percent of the patients over sixty-ve years old had a fracture malunion at the time of the latest follow-up. The authors found that malalignment did not increase the relative risk of a poor functional outcome in patients sixty-ve years of age or older. Our cohort was clearly older and had a more representative sample of fracture patterns, which included types A, B, and C. Despite these differences, our results support their nding that malunion is not associated with poor functional results. Young et al.23 evaluated whether the results of nonoperative treatment of distal radial fractures in the elderly are sustainable in the long term. They reviewed the cases of eighty-ve patients who had been randomized to treatment with casting or external xation and had been followed for a mean of 7.8 years. The mean age was sixty years for the group treated with casting compared with fty-four years for the external xation group. At the time of the latest follow-up, the improved radiographic results seen in the patients in the external xation group did not translate into better clinical outcomes. Again, we found similar results in our older, potentially lower-demand patients.

The major limitation of this retrospective study is the fact that, although both groups of patients were elderly, the nonoperative group was signicantly older by three years. This difference may represent some bias toward lower expectations in the nonoperative group. This is intuitively countered by the fact that no difference in baseline function was seen, indicating that functional age did not correlate with chronological age in our study. While the DASH is technically a measure of disability, we chose to use the DASH as a measure of functional outcome. One must take into account that while function and disability may be related, they may not be mutually exclusive. Another limitation is the variation in radiographic parameters as measured at each visit. Differences in radiographic technique and human error could account for differences between groups. Also, the research assistants involved in the data collection of this study were not blinded to treatment type and may have introduced bias. Finally, length of follow-up in this study is a limitation. It is possible that with longer-term followup, the posttraumatic arthritis noted at one year could begin to impact function. In conclusion, it appears that a subset of elderly patients functions well with nonoperative treatment of a distal radial fracture. Despite fracture malunion and somewhat diminished grip strength, the older patients who were treated nonoperatively had pain and functional scores equivalent to those of elderly patients who had surgical treatment for a displaced distal radial fracture, at all time points up until one year. n

K.A. Egol, MD M. Walsh, PhD S. Romo-Cardoso, MD Seth Dorsky, BS N. Paksima, DO New York University Hospital for Joint Diseases, 301 East 17th Street, Suite 1401, New York, NY 10003. E-mail address for K.A. Egol: kenneth.egol@nyumc.org

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19. Hattori Y, Doi K, Estrella EP, Chen G. Arthroscopically assisted reduction with volar plating or external xation for displaced intra-articular fractures of the distal radius in the elderly patients. Hand Surg. 2007;12:1-12. 20. Horne JG, Devane P, Purdie G. A prospective randomized trial of external xation and plaster cast immobilization in the treatment of distal radial fractures. J Orthop Trauma. 1990;4:30-4. 21. Jaremko JL, Lambert RG, Rowe BH, Johnson JA, Majumdar SR. Do radiographic indices of distal radius fracture reduction predict outcomes in older adults receiving conservative treatment? Clin Radiol. 2007;62:65-72. 22. Wong TC, Chiu Y, Tsang WL, Leung WY, Yam SK, Yeung SH. Casting versus percutaneous pinning for extra-articular fractures of the distal radius in an elderly Chinese population: a prospective randomised controlled trial. J Hand Surg Eur Vol. 2010;35:202-8. 23. Young CF, Nanu AM, Checketts RG. Seven-year outcome following Colles type distal radial fracture. A comparison of two treatment methods. J Hand Surg Br. 2003;28:422-6.