“Age Is Just a Number”: Distal Radius Fractures in Patients Over 75

Abstract

Background: Management of distal radius fractures in patients over 65 is a topic of significant study, but there are variations within this group in terms of independence and activity level. This study compares the outcomes of operative distal radius fracture treatment in patients over 75 with those aged 65 to 74, to evaluate the effects of patient demand and advanced age on outcome. Methods: A retrospective review of a single-institution distal radius fracture database was performed. All patients over age 65 were evaluated for inclusion. Patient factors including activity, independence level, and quick disabilities of the arm, shoulder and hand (QuickDASH) score were recorded. Patients were selected for open reduction and internal fixation (ORIF) based on a discussion between the patient and the treating surgeon. Outcome measures including QuickDASH were recorded at 1-year post-injury. Patients aged 65 to 74 and 75 and over were compared to evaluate for demographic, functional, and outcome differences. Results: In all, 75 patients were included in the study. Fifty-one patients were aged 65 to 74, and 24 patients were aged over 75. The majority of patients rated themselves as “completely independent” and “active,” the highest levels of each. There was no difference in QuickDASH scores between those patients who rated themselves as completely partially independent, or active versus moderately active. There was no statistically significant difference in QuickDASH or range of motion parameters at final follow-up. Conclusions: This study demonstrates that, in a group of patients with high levels of independence and activity, outcomes are similar in patients aged 65 to 74 and over 75 at 1 year following distal radius ORIF.

Introduction

As the population ages, fragility fractures are expected to constitute an increasing burden on patients and the health care system.^1-3 Distal radius fractures are the most common fragility fracture of the upper extremity and are associated with an increased risk of fragility fractures at other sites.^4,5

The management of distal radius fractures in patients over 65 years of age continues to be a topic of study. Multiple groups have found no difference in long-term outcomes between operatively and nonoperatively managed fractures in this population.^6-8 Furthermore, there does not appear to be a correlation between “acceptable” radiographic reduction parameters and patient-reported outcomes in nonoperatively managed distal radius fractures in older patients, indicating that surgery may be unnecessary even in more displaced or comminuted injuries.^9-11 Nonetheless, many patients continue to be treated operatively for these injuries. Proponents of surgery cite improved function and decreased pain in the first 6 months following surgery, as well as improved radiographic outcomes. ⁶ More recent studies support this trend demonstrating a benefit to operative fixation of distal radius fractures in the elderly population.^12,13 The current recommendation by the American Academy of Orthopaedic Surgeons does not recommend for or against surgical management of distal radius fractures in the elderly. ¹⁴

Analyses of distal radius fracture outcomes in patients >65 years old are complicated by the heterogeneity of this population. As patients approach 80 years of age, fractures become more common and patients are likely to require increased assistance with activities of daily living. ¹⁵ Considerations governing distal radius treatment options are complicated in this group by conflicting trends. Although older, lower-demand patients appear better able to tolerate malunion following distal radius fracture, ¹⁶ these patients are more likely to require upper extremity function for mobility. ¹⁷

Given the expected increase in incidence of distal radius fractures among patients greater than 75 years of age, more information is needed to evaluate whether current recommendations adequately address this subgroup of very elderly patients. The purpose of this study was to evaluate surgical outcomes in patients over 75 years of age compared to patients aged 65 to 74 years of age. We hypothesized that functional outcomes are independent of age in a “physiologically young” subset of patients over age 75, and that results after surgery are comparable to those in patients aged 65 to 74.

Methods

Patient Identification and Data Collection

This study was a retrospective review of a distal radius fracture database from a single institution. All patients aged 65 or greater presenting to our institution with an acute distal radius fracture from 2006 to 2018 were evaluated for inclusion in the database. Patients who declined to participate were excluded from the database. Data were collected at the initial visit and at each subsequent visit until completion of treatment. These data included demographic information, radiographic parameters, patient-related outcome measures including Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and visual analog scale (VAS) pain scales, comorbidities, and information regarding treatment method and complications. Patients were also asked to rate their levels of independence on a 7-point scale (ranging from complete independence to complete dependence), and activity on a 4-point activity level scale (ranging from active to inactive).

The decision for treatment was made per the discretion of the attending surgeon, in consultation with the patient, as well as his or her caregivers where applicable. The decision took into account a discussion of the patient’s activity level, functional demands, level of independence, and tolerance for the risk and pain of surgery. Patients were selected for surgery based upon fracture morphology, their overall level of activity including activities of leisure and sport whose medical comorbidities did not unduly elevate the risk of surgery. Operative treatment consisted of open reduction and internal fixation with a volar locking plate, with the plate manufacturer and model dependent on the treating surgeon’s preference. Three fractures were treated by percutaneous pinning, followed by 6 weeks of cast immobilization prior to pin removal. One fracture was treated with a spanning external fixator with a radial styloid pin and a soft dressing, with the fixator removed at 6 weeks postoperatively. These 4 patients were all in the 65- to 74-year-old group. All other fractures were treated with a volar locking plate through a modified volar Henry approach. All volar locking plate patients were immobilized during the first postoperative week in a volar plaster orthosis. Patients were then transitioned to a custom-made thermoplastic volar orthosis and referred to occupational therapy.

Statistical Analysis

The 2-tailed student’s T-test was used to compare injury and demographic factors of patients aged 65 to 74 with those aged 75 and over. A post-hoc power analysis was performed, and demonstrated >95% power to detect a QuickDASH difference of 15.9 points or greater (the minimum clinically important difference) between groups. ¹⁸

Categorical demographic and comorbidity data were analyzed for differences between groups using the chi-square test. A post-hoc power analysis was performed, which failed to demonstrate 80% power to find differences between groups in the categories of osteoporosis, self-described independence and activity level, fracture classification, and hand dominance.

Individual univariate linear regression analyses were performed to evaluate the correlation of QuickDASH score at 1 year with age, preoperative dorsal angulation, and preoperative articular stepoff.

Results

In all, 118 patients aged 65 or greater with distal radius fractures were identified in the database. Twenty-nine patients were excluded for inadequate follow-up. Fourteen patients had adequate length of follow-up but were treated nonoperatively and were excluded. In total, 75 patients were identified for inclusion in the study and had average final follow-up of 13.4 months (range: 10-41 months). Fifty-one patients were aged 65 to 74 (Group 1, average age 68.3), and 24 patients were aged over 75 (Group 2, average age 80.1). Chi-square testing demonstrated no statistically significant difference between groups with regard to AO fracture classification, patient history of osteoporosis, or dominance of injured extremity. Demographic information is included in Table 1. Preoperative radiographic parameters for the groups are listed in Table 2.

Table 1.

Study Group Demographics.

Group characteristic	Group 1	Group 2	Chi square probability
N	51	24
Age	65.3 (65-73)	80.2 (75-88)
Gender	47/51 Female (92%)	22/24 Female (92%)
BMI	27.1	25.7
Dominant wrist injured	22	10	>.5
Nondominant wrist injured	29	14	>.5
AO Type 1 or 2	14	6	>.5
AO Type 3	12	6	>.5
Osteoporosis	16	9	>.5
No osteoporosis	19	3	>.5

Note. Age is listed as mean (range). Osteoporosis diagnosis was based on a clinical diagnosis in the patient’s medical records or a self-reported diagnosis of osteoporosis. There was no significant difference in BMI between groups. BMI = body mass index.

Table 2.

Preoperative Radiographic Parameters.

Radiographic parameter	Group 1	Group 2	P
Initial radial height (mm)	9.6	9.8	.88
Initial radial inclination (deg)	21.9	21	.84
Initial volar tilt (deg)	4.5	6.9	.88
Initial intraarticular displacement (mm)	2.8	3	.84

Preoperatively, patients were asked to self-rate their activity and independence levels. Thirty-nine patients chose to report their levels of activity and independence. The majority rated themselves as “completely independent” and “active,” the highest levels of each. There was no significant difference noted, as determined by chi-square testing, between groups with regards to the proportion of patients describing themselves as “completely independent” or “active.” All patients who did not describe themselves as “completely independent” or “active” described themselves as having “modified independence” or being “moderately active,” the second-highest categories. These data are presented in Table 3.

Table 3.

Analysis of Categorical Variable Differences Between Groups.

Independence and activity level	Group 1	Group 2	Chi square probability
Complete independence	19	10	>.5
Other independence	7	5	>.5
Active	11	6	>.5
Other activity	15	9	>.5

Note. The number of patients reporting the indicated levels of activity and independence are displayed. All variables demonstrate no significant difference between Groups 1 and 2, indicating no significant difference between groups with regards to the proportion of “completely independent” and “active” patients.

There was no statistical difference in QuickDASH scores within either age group or in the cohort as a whole between those patients who rated themselves as completely independent versus partially dependent, or those who rated themselves active versus moderately active, moderately inactive, or inactive. T-testing comparing the 2 groups demonstrated no statistically significant difference in QuickDASH or range of motion parameters at 12-month follow-up. These data are presented in Table 4.

Table 4.

Postoperative Outcome Measures.

Outcome measure	Group 1	Group 2	P
Complications	1 (2%)	0
QuickDASH	9.7	11.9	.63
Flexion	55.5	50.4	.29
Extension	52.4	48	.31
Pronation	87.9	83.8	.61
Supination	83.5	83.3	.97
Grip strength (lb)	39.9	34.9	.51
Pinch strength (lb)	11.9	7.8	.86

Note. Range of motion measurements are given in degrees, and grip and pinch strength are given in Newtons.

Linear regression modeling demonstrated no significant correlation between age, preoperative dorsal angulation, or preoperative articular stepoff and QuickDASH at 1 year. There was 1 complication noted in this series. One patient in Group 1 was treated with an external fixator and developed digital stiffness requiring extensor tenolysis.

Discussion

The treatment of distal radius fractures in the elderly has undergone extensive study, with data from large database studies supporting equivalent results after operative and nonoperative management.^6,8 While nonoperative treatment is well-supported at a population level, patients of this age group vary a great deal in their functional status and health. As a result, there continues to be a proportion of patients aged 65 and older who are treated operatively for distal radius fractures. ¹⁹

Furthermore, as patient age increases over 75 years, considerations associated with advanced age become ever more pressing. These include the independence, functional demands, activity level of the patient, other medical comorbidities, decreasing bone density, and need for ambulatory aids.

Within this group, however, there is a large variation in patient health status, ranging from the extremely frail to completely independent, athletically active, physiologically healthy patients. While guidelines based on large studies with limited granularity would seem to recommend nonoperative treatment for these patients, the argument can be made that they should be treated based on their “physiological age.”

Although open reduction internal fixation (ORIF) of distal radius fractures continues to be performed in the elderly, there is limited large-series data to support this treatment. This is likely due to the above-mentioned heterogeneity of the elderly population, which greatly complicates statistical analysis. There is some evidence correlating radiographic and clinical outcomes in the elderly, however. A 2014 study evaluated 52 active, healthy elderly patients with nonoperatively treated distal radius fractures, and found that volar tilt and ulnar variance correlate with Mayo wrist and DASH scores. ²⁰ This provides support for the practice of performing ORIF to improve radiographic parameters of badly displaced fractures. Critically, the study focused on the “active elderly” population, those who are more similar to younger patients in terms of demand and activity level. A 2019 study of 96 patients with nonoperatively treated distal radius fractures found similar results, with ulnar variance and angulation correlating with postoperative strength and range of motion. These authors, too, caution the reader that malalignment has greater consequences in the “active elderly” population. ²¹

Our study hypothesized that patients aged 75 or older would have outcomes equivalent to those aged 65 to 74 following distal radius fracture ORIF. We found no significant difference in QuickDASH scores between the 2 groups at 1 year. Furthermore, range of motion measurements at final analysis did not differ between groups.

The QuickDASH scores reported in both groups were low (9.7 in Group 1, 11.9 in Group 2), indicating a limited degree of fracture-related disability at 1 year. The minimum clinically significant difference for QuickDASH scoring is 15.9 points, ¹⁸ with a normative value of 22 for men and 33 for women aged 70 to 79 in a 2014 study. ²² The functional outcome score in Group 2 patients is thus indistinguishable from those of random selections from this population. This may be confounded to some extent by patient activity modification, in which a decrease in demanding activity obviates patient disability. Without a standardized set of tasks or activities with which to evaluate patients, this cannot be ruled out.

It is critical to note that the 2 groups did not differ significantly in demographic factors other than age, or in self-reported level of activity or independence. Despite being aged > 75, the majority of patients in Group 2 reported themselves as completely independent and active, with the remainder describing themselves as moderately active or “modified independent.” Thus, patients within the 75+ group were likely selected for their relatively robust health and high level of function which may have affected the functional outcomes in this group.

The limitations of this study include its retrospective nature and lack of randomization, as well as concerns regarding its’ power to detect subtle demographic differences between groups, or differences in early recovery.

As this was a retrospective study, patients aged 75 and above were selected for surgery at the surgeon’s discretion. The absence of randomization means that this study is not applicable to all patients in these age groups, and the demographic information in Table 3 provides a guideline as to the applicable patient group. Furthermore, a post-hoc power analysis failed to demonstrate the ability to discern a difference between groups in terms of independence, activity level, and dominance of injured extremity. While these groups appear prima facie to demonstrate the similar levels of activity, a larger sample size would be required to demonstrate that the 2 groups are truly equivalent.

Furthermore, there may be reporting biases at work—self-reported activity levels are not necessarily the most accurate means of assessing patient activity, especially if patient expectations of what “active” or “independent” means change with age. A more objective measure of activity and independence may demonstrate more subtle differences between the groups.

This study also lacked a control group of nonoperatively treated patients aged 75 or greater. This prevents any conclusions from being drawn regarding the relative efficacy of operative versus nonoperative treatment in these patients. To provide the answer to this question, a prospective randomized trial would need to be performed specifically on patients over 75 selected for high levels of activity and independence.

One of the major arguments for fixation of distal radius fractures in the elderly population is improved function during the early postoperative period. This can take the form of earlier release from immobilization (eg, transitioning to a removable splint 2 weeks after surgery, allowing early wrist ROM with therapy and hygiene at home), or of earlier return to weight bearing. Our study did not assess the patient experience of recovery, which would be required to assess the dysfunction and temporary disability associated with casting versus early mobilization.

In “functional quadrupeds,” patients who require their upper extremities for mobilization with assistive devices, early weight bearing is a critical consideration that may tilt the scales toward a decision for surgery. ²³ Alternative ORIF constructs using a bridge plate allow for immediate weight bearing, and are highly useful in this population. ²⁴ This patient population, however, has a different set of concerns than the “active elderly” evaluated in this study. Furthermore, platform weight bearing can mitigate some of these concerns without the risk, pain, and expense of surgical intervention.

Despite these limitations, however, the finding of the study, that active, independent patients over the age of 75 benefit similarly to less-elderly patients following distal radius ORIF, does indicate the need for further studies of the utility of surgical care in “physiologically young” patients within this subgroup.

Distal radius fractures in the elderly are a common diagnosis, and 1 associated with significant morbidity. There have been several well-constructed studies demonstrating equivalent results with operative and nonoperative management in elderly patients. Nonetheless, this study should serve as a note of caution, that each patient has her own set of needs and level of demand, and should be treated based on these individualized factors rather than a strict age cutoff.