This guideline is based on 2 high quality studies, and 11 moderate quality studies comparing operative and nonoperative treatment in those >65 years of age. Some studies demonstrated improvements in patient reported outcomes in the short term (usually less than 3 mo.). Studies consistently showed no difference in patient reported outcomes in the long-term (1 year or greater) despite improvements in radiographic parameters as this is currently the most common metric (parameter or variable) cited in the relevant literature. The term geriatric was used as the spirit of this guideline is to address distal radius fractures in those patients with low functional demand. Age is commonly used as a proxy for functional demand when studying this population, often described as 65 and greater in age.
Risks and Benefits of Implementation
The workgroup acknowledges that age, as used in the cited evidence as well as this clinical practice guideline, is used as a proxy for functional demand. As such, a high functioning patient with high functional demands, despite having an age greater than 65, may benefit from operative fixation based on the literature supporting fixation in young, active patients. At the same time, there may be low functioning younger patients with low functional demands, that despite having an age less than 65, that may benefit from non-operative treatment. A patient-centered discussion understanding an individual patient’s values and preferences can inform appropriate decision making to ensure his/her age and functional demands align to appropriately apply this clinical practice guideline. The recommendations regarding operative treatment are principally based upon literature studying distal radius fracture as an isolated injury. Mitigating circumstances may also be factors in the shared decision-making process.
Future Research
Research using other tools that better describe a patient’s functional demand instead of age are needed. These tools could better inform point of care decisions for the treatment of distal radius fractures in the elderly that avoid the aforementioned risks of treatment based on age alone. While the workgroup acknowledges that functional demand would be a better explanatory variable for understanding the benefits of operative treatment, this clinical practice guideline uses age greater than 65 as this is what is used in the literature.
- Saving, J., Severin Wahlgren, S., Olsson, K., Enocson, A., Ponzer, S., Skoldenberg, O., Wilcke, M., Mellstrand Navarro, C. Nonoperative Treatment Compared with Volar Locking Plate Fixation for Dorsally Displaced Distal Radial Fractures in the Elderly: A Randomized Controlled Trial. Journal of Bone & Joint Surgery - American Volume 2019; 11: 961-969
- Arora, R., Lutz, M., Deml, C., Krappinger, D., Haug, L., Gabl, M. 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. Journal of Bone & Joint Surgery - American Volume 2011; 23: 2146-53
- Moroni, A., Vannini, F., Faldini, C., Pegreffi, F., Giannini, S. Cast vs external fixation: a comparative study in elderly osteoporotic distal radial fracture patients. Scandinavian Journal of Surgery: SJS 2004; 1: 64-7
- Martinez-Mendez, D., Lizaur-Utrilla, A., de-Juan-Herrero, J. Intra-articular distal radius fractures in elderly patients: a randomized prospective study of casting versus volar plating. Journal of Hand Surgery: European Volume 2018; 2: 142-147
- Bartl, C., Stengel, D., Bruckner, T., Gebhard, F., Orchid Study Group The treatment of displaced intra-articular distal radius fractures in elderly patients. Deutsches Arzteblatt International 2014; 46: 779-87
- Roumen, R. M., Hesp, W. L., Bruggink, E. D. Unstable Colles' fractures in elderly patients. A randomised trial of external fixation for redisplacement. Journal of Bone & Joint Surgery - British Volume 1991; 2: 307-11
- Horne, J. G., Devane, P., Purdie, G. A prospective randomized trial of external fixation and plaster cast immobilization in the treatment of distal radial fractures. Journal of Orthopaedic Trauma 1990; 1: 30-4
- Schmalholz, A. Bone cement for redislocated Colles' fracture. A prospective comparison with closed treatment. Acta Orthopaedica Scandinavica 1989; 2: 212-7
- Hegeman, J. H., Oskam, J., Van Der Palen, J., Ten Duis, H. J., Vierhout, P. A. M. Primary external fixation versus plaster immobilization of the intra-articular unstable distal radial fracture in the elderly. Aktuelle Traumatologie 2004; 2: 64-70
- Földhazy, Z., Leif, Ahrengart[RJ1] [RJ2] . External fixation versus closed treatment of displaced distal radial fractures in elderly patients: A randomized controlled trial. Current Orthopaedic Practice 2010; 3: 288-295
- Sanchez-Sotelo, J., Munuera, L., Madero, R. Treatment of fractures of the distal radius with a remodellable bone cement. Journal of Bone and Joint Surgery - Series B 2000; 6: 856-863
- Wong, T. C., Chiu, Y., Tsang, W. L., Leung, W. Y., Yam, S. K., Yeung, S. H. Casting versus percutaneous pinning for extra-articular fractures of the distal radius in an elderly Chinese population: a prospective randomised controlled trial. Journal of Hand Surgery: European Volume 2010; 3: 202-8
- Azzopardi, T., Ehrendorfer, S., Coulton, T., Abela, M. Unstable extra-articular fractures of the distal radius: a prospective, randomised study of immobilisation in a cast versus supplementary percutaneous pinning. Journal of Bone & Joint Surgery - British Volume 2005; 6: 837-40