0
Commentary and Perspective   |    
Commentary on an Article by K.A. Egol, MD, et al.: “Distal Radial Fractures in the Elderly: Operative Compared with Nonoperative Treatment”
Lisa K. Cannada, MD1
1 Department of Orthopaedic Surgery, Saint Louis University, St. Louis, Missouri
View Disclosures and Other Information
The author did not receive any outside funding or grants in support of her research for or preparation of this work. Neither she nor a member of her immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Aug 04;92(9):e11 1-2. doi: 10.2106/JBJS.J.00681
The main article is available here
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case
The authors hit the jackpot in terms of interest and applicability of a research topic. A distal radial fracture is one of the most common fractures, representing 16% of all fractures1. The treatment of distal radial fractures in patients over sixty-five years old is an important topic in light of the aging population, and these patients may have substantial comorbidities to consider when a treatment plan is formulated. In addition, the trends in the treatment of distal radial fractures have changed over the years. There were numerous articles in the 1990s on external fixation, after which the use of a dorsal buttress plate became popular. Combination treatment, such as percutaneous pin fixation along with use of an external fixator in more severe fractures, then became widely used. However, the evolution of the volar locked plate in the distal end of the radius was targeted for use in elderly patients with osteoporotic bone. The use of the locked plates has provided one example of how technology has changed treatment in orthopaedic surgery in recent years. The use of a volar locked plate compared with the other treatment methods may provide a desired radiographic outcome2. The question remains as to how a "perfect" radiographic result equates with functional outcome.
This study compared operative and nonoperative treatment for distal radial fractures. 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 with either an external fixator or a plate. The strength of the study is that it addresses a topic of interest that affects the clinical practice of most orthopaedic surgeons. This was a case-control study; however, the patients made the decision as to whether to proceed with surgery for the displaced distal radial fractures. This leaves the reader to ponder the self-selection bias of patients who did not want surgery. Were the patients who did not select operative treatment sicker? Did they have fewer functional demands? Perhaps the patient who was physiologically older did not care as much about the final result in terms of the functional outcome. Another weakness in this study is that the duration of follow-up was only one year, and one year may not be enough for the complications of posttraumatic arthritis to manifest. It was interesting that, in the operative group, the Orthopaedic Trauma Association classification with the largest number of fractures was type A. As this is an extra-articular fracture, the question remains as to whether the surgery was actually necessary in these patients. Although these patients were good candidates to be allowed to choose their treatment, the choice would be more difficult for patients with the more severe type-C fracture.
The authors found differences between the operative and nonoperative groups with regard to grip strength at the time of the one-year follow-up and wrist range of motion at the time of the six-month follow-up, but they found no difference in functional outcome or complications in the patients. Questions remain with regard to the optimum treatment for this fracture in this age group. In the study, both a locked plate and external fixation were used for patients treated operatively, and the results between those groups were not significantly different. Aktekin et al. recently evaluated external fixation compared with cast treatment in patients over sixty-five years old with dorsally displaced distal radial fractures, and the outcomes, including scores on the Disabilities of the Arm, Shoulder and Hand questionnaire, were similar3. Significant differences were noted for wrist extension and ulnar deviation, both of which were better in the external fixation group. The present study did not find significant differences in wrist extension and ulnar deviation at the time of the one-year follow-up.
Is fixation with a volar locked plate the answer for surgical treatment of elderly patients with distal radial fractures? The radiographic results may be better, but the question we should be asking is whether plate fixation with earlier mobilization leads to better functional outcomes? The problem has not been directly compared prior to this investigation, and this was just a case-control study. Most patients who are treated surgically have unstable fracture patterns and/or unacceptable closed reduction. The functional outcome of the patients managed surgically in this study remained the same as that of the patients who were not managed surgically.
Abramo et al. compared open reduction and internal fixation with closed reduction and external fixation in a randomized study of fifty patients4. This was not specifically an older age group, but the authors found better grip strength, better range of motion, and fewer malunions with open reduction than with external fixation. However, there was no difference in subjective outcome. With the variety of studies published on this subject, one can find support for whatever treatment method is chosen. What is important is to provide the patient and the family with results from the literature to assist their decision-making.
If the abstract is read casually, one might conclude that operative care of distal radial fractures in older patients may not be warranted. However, it is important to remember that there are patients over sixty-five years old who may benefit from surgical fixation and have good results. Likewise, we want to be sure that patients who are fearful of surgery are aware that closed treatment can lead to a good functional result even if there is weakness in grip strength at one year. The question to consider, on the basis of these results, is whether the surgeon would be willing to accept outcomes such as deformity, loss of grip strength, and decreased motion, which were not found to have a significant impact on the functional status of the patients in this study.
Overall, the outcomes of treatment of distal radial fractures in the elderly were well evaluated in this paper. However, it is important to be careful to read between the lines and draw your own conclusions when using this information to discuss treatment options with patients and their families. Remember, someday you may be that sixty-five-year-old who needs to make a decision as to what treatment you want. This article can be used as a point of reference in the treatment of a patient and also to direct further research studies on this topic.
Ruch  DS;  McQueen  MM. Distal radius and ulna fractures.  In: Bucholz  RW;  Heckman  JD;  Court-Brown  CM;  Tornetta  P. Rockwood and Green's fractures in adults. 7th ed,  vol 1. Philadelphia: Lippincott Williams & Wilkins; 2009.  p829-80.
 
Figl  M;  Weninger  P;  Jurkowitsch  J;  Hofbauer  M;  Schauer  J;  Leixnering  M. Unstable distal radius fractures in the elderly patient—volar fixed-angle plate osteosynthesis prevents secondary loss of reduction. J Trauma.  2010;68:992-8.[PubMed]
 
Aktekin  CN;  Altay  M;  Gursoy  Z;  Aktekin  LA;  Ozturk  AM;  Tabak  AY. Comparison between external fixation and cast treatment in the management of distal radius fractures in patients aged 65 years and older. J Hand Surg Am.  2010;35:736-42.[PubMed][CrossRef]
 
Abramo  A;  Kopylov  P;  Geijer  M;  Tägil  M. Open reduction and internal fixation compared to closed reduction and external fixation in distal radial fractures: a randomized study of 50 patients. Acta Orthop.  2009;80:478-85.[PubMed] [CrossRef]
 

Submit a comment

References

Ruch  DS;  McQueen  MM. Distal radius and ulna fractures.  In: Bucholz  RW;  Heckman  JD;  Court-Brown  CM;  Tornetta  P. Rockwood and Green's fractures in adults. 7th ed,  vol 1. Philadelphia: Lippincott Williams & Wilkins; 2009.  p829-80.
 
Figl  M;  Weninger  P;  Jurkowitsch  J;  Hofbauer  M;  Schauer  J;  Leixnering  M. Unstable distal radius fractures in the elderly patient—volar fixed-angle plate osteosynthesis prevents secondary loss of reduction. J Trauma.  2010;68:992-8.[PubMed]
 
Aktekin  CN;  Altay  M;  Gursoy  Z;  Aktekin  LA;  Ozturk  AM;  Tabak  AY. Comparison between external fixation and cast treatment in the management of distal radius fractures in patients aged 65 years and older. J Hand Surg Am.  2010;35:736-42.[PubMed][CrossRef]
 
Abramo  A;  Kopylov  P;  Geijer  M;  Tägil  M. Open reduction and internal fixation compared to closed reduction and external fixation in distal radial fractures: a randomized study of 50 patients. Acta Orthop.  2009;80:478-85.[PubMed] [CrossRef]
 
Accreditation Statement
These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
CME Activities Associated with This Article
Submit a Comment
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe





Related Content
The Journal of Bone & Joint Surgery
JBJS Case Connector
Topic Collections
Related Audio and Videos
PubMed Articles
Clinical Trials
Readers of This Also Read...
JBJS Jobs
02/05/2014
Oregon - The Center - Orthopedic and Neurosurgical Care and Research
04/16/2014
Connecticut - Yale University School of Medicine
04/02/2014
Illinois - Hinsdale Orthopaedics