Distal radial fractures in the elderly

Fractures of the distal radius are one of the most common orthopaedic fractures within predominantly Caucasian and older populations. These fractures result from low injury trauma and increase in incidence due to the effects of post-menopausal osteoporosis in women. There are various management and treatment techniques for distal radial fractures. This includes both conservative and surgical treatment including open reduction internal fixation (ORIF), K-wires, use of pins and volar locking plates. A majority of distal radial fractures are treated with cast immobilisation however more complicated fractures require additional operative management. 

Within elderly populations it becomes important to consider the anaesthetic complications which can arise as a result of these surgical treatments. A thorough preoperative assessment is required to reduce these complications and to ensure that local ansaesthisa can be used to minimise discomfort. There is not one treatment that will be effective in treatment of all types of fractures. Therefore, one has to look at the specific characteristics of each fracture.

BackgroundFractures of the distal radius are one of the most common orthopaedic fractures within predominantly Caucasian and older populations.1 Fractures of the distal radius within the older population usually result from low-energy trauma, such as a fall from a standing height. In contrast the mechanism in younger patients usually involves high energy trauma such as road traffic accidents. This pattern reflects how the bone loss from osteoporosis makes fractures of the distal radius more likely in the older population.²

It has been estimated that, at 50 years of age, a Caucasian female in the USA or Northern Europe has a 15% life-time risk of a distal radius fracture; whereas a male has a lifetime risk of just over 2%.³

A recent prospective survey of Colles’ fracture in patients aged 35 years and above, in six centres in the UK, reported the overall annual incidence of this fracture to be 9/10,000 in men and 37/10,000 in women.2 Distal radial fractures are usually treated in an outpatient setting with around 20% of patients (mainly older) requiring hospital admission.^3,4 The impact of distal radial fractures on patients and healthcare resources is substantial.⁵ Fractures of the hand are a common injury and if inappropriately managed, may leave severe functional deficit.6 There are a number of options for stabilisation and treatment of these fractures; namely conservative or surgical. Conservative management includes cast immobilisation. There are many surgical options available such as internal fixation, external fixation, percutaneous pinning and bone substitutes.⁷ This review looks at the current literature related to the treatment and management of distal radius fractures.

Common distal radial fractures in the elderlyDistal radial fractures that occur in elderly patients have different characteristics to those fractures seen in younger patients.8 Colles’ fracture usually results following low energy trauma such as a patient falling on the dorsiflexed hand, breaking the radius transversely just above the wrist. This is often associated with osteoporotic patients.9 Another two fractures that are less common than the Colles’ fracture are Smith’s and Barton’s fracture. Smith’s fracture is described as a true reversed Colles’ fracture and involves a transverse fracture of the lower radius with a forward shift and tilt. This is the opposite to the Colles’ that has a dorsally displaced fragment rather than ventral. This is a rare fracture and occurs mainly in elderly women.⁹

The Barton’s fracture, otherwise known as fracture dislocation, is commoner. The radial fracture is oblique and it extends upwards and forwards from the wrist joint (intra-articular).¹⁰ The intra-articular nature of the fracture is what distinguishes this from a Colles’ or Smith’s fracture and is usually caused by falling on an extended and pronated wrist.

Mechanism of injuryMost injuries of this sort occur due to falls on the hand. To understand the mechanism of injury further it helps to think of the distal forearm as divided into three columns: ulnar, intermediate and distal column. The proposed theory of load transmission through the wrist suggests that small loads are transmitted via the radial column which acts primarily as a stabiliser.

The intermediate column serves primarily for load transmission and axial loads from the lunate and the proximal part of the scaphoid are transmitted along this column. Finally, the ulnar column has the triangular fibrocartilage, which helps to transmit half of the axial load. When a patient’s hand strikes the ground we have variable dorsal and lateral forces, which travel through the carpal bones to the lower end of the radius, which results in distal radius fractures.¹¹

Hyperflexion of the wrist joint has been identified as the single most common injury mechanism in distal radial fractures. This determines the compression and tension forces applied to the radiocarpal joint as a result of a fall.¹¹ All in all, the exact position of the hand at the time of impact with the quality of the bone (osteoporosis) determines the different patterns of distal radial fractures. Many studies have established a clear correlation between an increased incidence of forearm fractures and decreased bone mineral density in postmenopausal women as a result of osteoporosis.

Classification¹²The Orthopaedic Trauma Association fracture classification defines distal radius fractures (23 A€“C). The classification is arranged in ascending order of severity according to the prognosis of the fracture, the morphologic complexities and also the difficulties in treatment. Type A distal radial fractures are those not involving the articular surface. Fractures which do involve the articular surface are divided into two groups; those which involve part of the articular surface (Type B) and those which involve all of the articular surface (Type C). Type B fractures are then subdivided into the following groups: group B1 fractures involve the sagittal plane; group B2, the dorsal rim (also known as Barton’s fracture); group B3, the volar rim (reverse Barton’s fracture). These are in turn further subdivided.

Compression fractures are considered as type C fractures, which are subdivided into three groups. Group C1 fractures are two-part articular fractures without metaphyseal fragmentation; group C2, two-part articular fractures in which the metaphysis is multifragmentary; group C3, fractures involving comminution of the articular surface. These are also further subdivided.

Accurate classification of complex fracture patterns may not always be possible when examining fractures using preoperative radiographs. However, the classification will prove extremely useful in trying to understand how to manage these fractures and in the evaluation of the outcome.

AnatomyThe distal end of the radius is the anatomical foundation of the wrist joint. The wrist joint is a synovial joint between the distal end of the radius and the articular disc overlying the distal end of the ulna, and the scaphoid, the triquetrium and the lunate. The wrist joint allows movement around two axes. In addition to the palmar and dorsal ligaments we have the radial and ulnar collateral ligaments, which reinforce the wrist joint and enable the joint to support axial load.¹³

The anatomic relationships of the dorsal radius, the extensor retinaculum, and the six dorsal extensor compartments are important in planning operative management and the placement of implants.¹⁴ The articular end of the radius slopes in an ulnar and palmar direction. The proximal carpal row will have a tendency to slide in an ulnar direction, resisted by the intracapsular and intraosseous carpal ligaments, because of this slope.¹⁵

The other distinct articular surface of the end of the radius is the sigmoid notch. The articulation is a trochoid joint. During rotation of the radius about the ulna in supination, the ulnar head displaces volarly in the notch, while in pronation it moves dorsally. The triangular fibrocartilage complex arises at the ulnar aspect of the distal radius and extends onto the ulnar styloid process and helps by acting as a crucial stabiliser of the distal radioulnar joint. Stability and mobility are ensured by the design of the radius and its interactions with its carpal and ulnar articulations. It becomes crucial that operative management of distal radial fractures does not result in deformity of these articulations as this can have a profound effect on the wrist joint as a unit.¹⁶

Conservative managementUltimately, the main aim of all forms of management is to restore full function and achieve early mobilisation to reduce the risk of poor outcome. Successful fracture management aims to achieve early fracture union without significant complications. If fractures are displaced significantly they need to be reduced to a satisfactory position. This can then allow adequate stabilisation for the fracture to heal. Stabilisation can be achieved using non-operative management.¹⁷ 

Closed reduction and cast immobilisation is the mainstay of treatment for minimally displaced, stable fractures. The duration of cast immobilisation for distal radial fractures remains a topic of debate. Currently, the decision for the duration of immobilisation of distal radial fractures is predominantly based upon the personal preferences of the treating surgeon. The recommended time is four to six weeks, however, for up to 30%. The effect of the duration of cast immobilisation on the fracture still remains unclear.18 Conservative management is indicated particularly in unstable fractures in the elderly population who are considered too frail to undergo surgery.19 A systematic review by Handoll et al in 2003 of 37 randomised trials compared the different types of closed reduction for displaced fractures. They concluded that there is a general insufficiency of evidence to inform which form of management is best, and clinicians should use the form of reduction they are most familiar with.²⁰

Operative managementOnce a fracture has been reduced, if adequate stabilisation cannot be provided by a plaster, then some form of operative stabilisation procedure is needed. This can be with K-wires or plates. These may need additional cast immobilisation. Sometimes, external fixators are also used. 

Kapandji wires Percutaneous pinning, or Kapandji or K-wiring is a simple, minimally invasive technique to maintain reduction of the fracture and prevent re-displacement of the fragments.^21,22 In the US in 1999, orthopaedic trainees treated 58% of distal radius fractures with percutaneous pinning and by 2007, only 19% of cases were treated with percutaneous pinning.²³ This was mainly due to the introduction of volar plating, but also due to the many complications that have been reported after retrograde pinning for distal radial fractures, including soft tissue irritation, injury to radial sensory nerve and extensor tendons, pain, algodystrophy, pin tract infection especially when left outside the skin and loss of reduction. Percutaneous K-wiring is a simple and cost-effective technique provided that the distal radius is not severely comminuted or osteoporotic.²² 

K-wiring involves the wires being inserted into the medullary canal through a dorsal cortex of the radial diaphysis in the forearm.24 Results from studies showed that intra-medullary K-wire fixation is an effective technique for stabilisation and prevention of secondary displacement of distal radial fractures. However, it must be noted that care is taken when selecting patients as this technique is not suitable for fractures with marked intra-articular or metaphyseal comminution.22 The incidence of infection with regards to this technique has been seen to increase with the length of time that the K-wires are left. This brings about a common debate relating to the duration of treatment with K-wires. As a result there is a trade-off between leaving the K-wires in situ for the full six weeks to fracture union and the increasing infection rate versus removing them earlier at four weeks and completing the treatment with a cast alone for the remaining two weeks.²⁵

Volar locking platesIn recent years, advancements in volar plating have been reflected by a rapid expansion in the popularity of such systems.²³ Volar locking plate systems have been shown to be the gold standard for fixation of these fractures with good to excellent objective and functional outcomes.26 The ability of these volar plates to maintain fracture reduction has previously been seen in clinical studies, where they have been used for distal radial fractures. In unstable distal radius fractures studies have shown that volar locking plates are considerably more stable than percutaneous pins. Volar plates also carry the advantage of neither needing to bury and remove at a later date, as they can generally be left in permanently. In some practices either no cast immobilisation or less than six-week immobilisation can be prescribed, which allows for earlier mobilisation.²⁵ Volar locking plating of distal radial fractures is a reliable form of treatment without substantial late displacement as confirmed by clinical studies,²⁶ but is a more extensive procedure as it involves open reduction with its associated risks.

Anaesthetic considerationsAnaesthesia is used with the surgical techniques for managing distal radial radial fractures in an attempt to minimise discomfort.²⁷ The type of anaesthesia (local or general) that is used becomes an important factor which you need to consider when trying to achieve the best possible outcome from treatment. Studies have shown that those patients who undergo open reduction internal fixation of distal radial fractures experience less pain and a better range of motion in the early post-operative stage if local anaethesia is used. The benefit of this anaesthesia appears to dissipate with time, however the positive benefits in terms of range of movement enables the patient to return to normal activities more rapidly.²⁸

Local anaesthesia has also been seen to be preferable with the treatment of Colles fractures in elderly patients. It has been seen to be preferable because of its easy administation and it appears to be more readily available than general anaesthesia.²⁹ With distal radial fractures we have added complications since a majority of patients will be elderly. Patients within this age bracket become particularly sensitive to stress, surgery, hospitalisation and anaesthesia. The reason why this occurs is only partly understood and since anaesthesia is deemed necessary to reduce discomfort during surgery, clinicians must ensure that a thorough preoperative assesment is carried out. This includes intraoperative management of any pre-existing disorders that the patient may have and finally a meticulous post-operative pain control regime.³⁰

Post-operative rehabilitation²⁷

Casting For bone healing you should expect a six-week period to ensure that the bone has achieved maximum strength. With a cast it is advised to support the fracture for one to two weeks in a removable plastic splint. 

Internal fixation For a patient who has undergone internal fixation treatment they can begin a gentle range of movement within one to two weeks. After this time a removable splint is used to support the fracture. The plate can either be left or surgically removed in a few weeks. 

External fixation The frame and pins are removed around three to six weeks after the surgery. This is then followed by a few weeks of a removable plastic splint to support the fracture.

Prevention measuresTreatment of osteoporosis can help prevent fractures, rather than to relieve pain or symptoms. All of the drug treatments for osteoporosis have been clinically tested and research has proven they reduce the risk of breaking bones.³¹ A healthy lifestyle can help to keep bones strong, but it is considered insufficient on its own to prevent fractures in people with osteoporosis who are at high risk of fracture. Complementary therapies have not been shown to reduce the risk of breaking a bone. If a patient is at high risk of a fracture it is unlikely therefore that a natural approach will be sufficient to reduce the risk of bones breaking. 

Drug treatments are available and include bisphosphonates such as alendronic acid /alendronate (Fosamax), risedronate (Actonel), ibandronate (Bonviva) and zoledronic acid (Aclasta). 

There are also the Selective Estrogen Receptor Modulators that include raloxifene (Evista). Then there is strontium ranelate (Protelos), denosumab (Prolia) and parathyroid hormone treatment such as teriparatide (Forsteo).³¹ Hormone replacement therapy (HRT) is sometimes recommended for women who are experiencing the menopause as it can help control symptoms.

ConclusionFractures of the distal radius are very common and there are nearly as many different options of managing this fracture as there are types of distal radial fractures. There is not one treatment that will be effective in treatment of all types of fractures. Therefore, one has to look at the specific characteristics of each fracture in order to determine the best possible treatment.

Conflict of interest: none declaredReferences

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