Abstract
Background
Treatment of distal radius fractures (DRFs) in patients aged >65 years is controversial. The purpose of this study was to identify what patient and fracture characteristics may influence the decision to pursue surgical versus nonsurgical treatment in patients aged >65 years sustaining a DRF.
Methods
We queried our institutional DRF database for patients aged >65 years who presented to a single academic, tertiary center hand clinic over a 5-year period. In all, 164 patients treated operatively were identified, and 162 patients treated nonoperatively during the same time period were selected for comparison (total N = 326). Demographic variables and fracture-specific variables were recorded. Patient and fracture characteristics between the groups were compared to determine which variables were associated with each treatment modality (operative or nonoperative).
Results
The average age in our cohort was 72 (SD: 11) years, and 274 patients (67%) were women. The average Charlson Comorbidity Index (CCI) was 4.1 (SD: 2.1). The CCI is a validated tool that predicts 1-year mortality based on patient age and a list of 22 weighted comorbidities. Factors associated with operative treatment in our population were largely related to the severity of the injury and included increasing dorsal tilt (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.05-1.12; P < .001) and AO Classification type C fractures (OR, 5.42; 95% CI, 2.35-11.61; P < .001). Increasing CCI was the only factor independently associated with nonoperative management (OR, 0.84; 95% CI, 0.72-0.997; P = .046).
Conclusion
Fracture severity is a strong driver in the decision to pursue operative management in patients aged >65 years, whereas increasing CCI predicts nonoperative treatment.
Keywords: distal radius, fracture/dislocation, diagnosis, elderly fractures, decision-making, wrist fractures, operative vs nonoperative
Introduction
Among patients aged ≥65 years, fractures of the distal radius are the second most common fracture with an approximate incidence of 640 000 cases per year in the United States. 1 This number continues to increase with an aging population. 2 Over the last 20 years, operative treatment of distal radius fractures (DRFs) in these patients has also increased. In 1997, 3% of Medicare patients with DRFs were treated with internal fixation compared with 22.6% in 2015.2-4 The aging US population and the rise in the incidence of operative treatment will increase the financial burden in the treatment of DRF. If the incidence of internal fixation reaches 50% in the Medicare population, annual DRF-related spending could reach nearly $240 million. 5
Historically, most DRFs in patients aged >65 years have been managed nonoperatively. 1 Several authors have reported similar functional outcomes in this patient population when comparing nonoperative with operative management.6-8 However, more recently, internal fixation and a focus on physiologic age have increased in popularity.8-10 Although a recent meta-analysis suggests that better grip strength and radiographic outcome can be expected after surgical intervention, 11 multiple high-quality studies have found no significant difference in short-term or long-term outcomes between operative and nonoperative treatment.7,12,13 As a result, the decision to operate is largely left to the individual patient and surgeon.
The decision-making for treatment of DRFs in patients aged >65 years often incorporates age, health, and the activity status of the patient as well as fracture displacement. 14 This is a collaborative process with input from both the surgeon and the patient with a shared decision and discussion that include the benefits of both operative and nonoperative management. Despite an extensive focus on fracture treatment outcomes, few studies have examined the patient-specific and fracture-specific factors that influence the treatment choice. This represents a significant gap in the current knowledge. The purpose of this study is to identify what patient and fracture characteristics may influence the decision to pursue surgical versus nonsurgical treatment in patients aged >65 years sustaining a DRF. We hypothesized that fracture displacement and patient activity level would significantly affect the decision to proceed with operative treatment. Identification of variables that have an influence on treatment choice will help to better understand how surgeons and patients choose treatment modalities.
Materials and Methods
This study was approved by the appropriate institutional review board (STUDY 2019P000922).
In this retrospective cohort study, we queried our institutional DRF database for patients aged >65 years who presented to a single academic, tertiary center hand clinic over a 5-year period (2015-2019) treated by 3 surgeons. In total, 164 patients treated operatively were identified. Of the 638 total patients treated for DRFs at our institution during this time period, 162 consecutive patients treated nonoperatively during the same time period were selected for comparison (total N = 326). The exclusion criteria were age less than 65 years, concomitant ipsilateral upper extremity injury, previous ipsilateral DRF, and open fracture. The decision was made to exclude open fractures because in our judgment this is a confounding variable for treatment choice.
Although there is no standardized decision-making method at our institution, all surgeons had similar methods. The surgeon-patient shared decision-making process at our institution involves a discussion of both operative and nonoperative treatment options with outlining the risks and benefits of both. Specific risks of closed treatment in a cast that are discussed include longer immobilization, risk of fracture displacement with time, and decreased grip strength. The specific risks of surgical treatment that are discussed include standard risks of anesthesia, standard surgical risks including infection, and damage to nearby anatomical structures. In addition, the risk of symptomatic hardware tendon rupture and the need for hardware removal are discussed.
In addition to treatment modality, the following patient and injury characteristics were recorded: age (years), body mass index (BMI; kg/m2), sex (men or women), smoking history (never, current, or prior), hand dominance (right or left), side of injury (right, left, or bilateral), whether the injury occurred secondary to a fall from height (yes or no), Charlson Comorbidity Index (CCI), level of independence (complete independence, modified independence, modified assistance, complete dependence, or unknown), patient-reported activity level prior to injury (active, moderately active, inactive, or unknown), as well as the presence of a prior fragility fracture (yes or no), presenting dorsal tilt (degrees), and AO Classification (A, B, or C).
Patient and injury characteristics were tallied. Continuous variables were reported as mean and standard deviation, whereas categorical variables were reported as counts and percentages. χ2 analysis was used to compare categorical variables between patients undergoing operative management with those undergoing nonoperative management. The Student t test was used to compare continuous variables between patients undergoing operative management with those undergoing nonoperative management. Multivariable logistic regression analysis was performed including the variables that were found to have significant or near-significant associations in bivariate analysis to determine which variables were associated with each treatment modality (operative or nonoperative). For the multivariable logistic regression analyses, patients who had unknown levels of independence at the time of injury or activity levels prior to injury were excluded (8 patients were excluded).
To ensure our analysis was appropriate, we considered the “rule of 10” as a starting point, which states that for every 10 events, 1 independent variable can be included in a logistic regression. However, more recent research has noted that this approach is too conservative and can be appropriately relaxed. 15 Thus, we ultimately included 15 independent variables in our logistical multivariable regression. Significance was set at P < .05 a priori.
Results
The average age in our cohort was 72 (SD: 11) years (range, 65-86 years), and 274 patients (67%) were women. The average CCI was 4.1 (SD: 2.1). Most patients (n = 254 [78%]) functioned with complete independence prior to their injury and considered themselves active in daily life (n = 200 [61%]). Most patients did not have a prior fragility fracture (n = 287 [88%]) before their current DRFs. These findings are summarized in Table 1. Of note, 22 patients were missing preoperative imaging for dorsal tilt evaluation and 11 patients for AO Classification.
Table 1.
Patient Characteristics.
| Characteristic | No. (%) or mean (SD) |
|---|---|
| Age, y | 72 (11) |
| Body mass index (n = 291) | 26 (6) |
| Gender | |
| Female | 274 (84) |
| Male | 52 (16) |
| Smoking history | |
| Never | 217 (67) |
| Current | 14 (4.3) |
| Prior | 95 (29) |
| Hand dominance | |
| Right | 270 (83) |
| Left | 22 (6.8) |
| Unknown | 34 (10) |
| Side of injury | |
| Right | 162 (50) |
| Left | 159 (49) |
| Bilateral | 5 (1.5) |
| Fall from height? | |
| Yes | 191 (59) |
| No | 135 (41) |
| Charlson Comorbidity Index | 4.1 (2.1) |
| Level of independence at time of injury | |
| Complete independence | 254 (78) |
| Modified independence | 48 (15) |
| Modified assistance | 11 (3.4) |
| Complete dependence | 5 (1.5) |
| Unknown | 8 (2.5) |
| Activity level prior to injury | |
| Active | 200 (61) |
| Moderately active | 106 (33) |
| Inactive | 11 (3.4) |
| Unknown | 9 (2.8) |
| Prior fragility fracture? | |
| Yes | 39 (12) |
| No | 287 (88) |
| Presenting dorsal tilt, deg (n = 304) | 18 (12) |
| AO Classification (n = 315) | |
| A | 140 (44) |
| B | 77 (24) |
| C | 98 (31) |
Bivariate comparisons of patient and injury characteristics between those treated operatively and those treated nonoperatively are presented in Table 2. At the time of injury, dorsal tilt was significantly higher in patients treated operatively, 24° (SD: 12°) versus 13° (SD: 10°), P < .05. Other radiographic parameters were similar between groups. All comparisons are summarized in Table 2.
Table 2.
A Comparison of Patient Characteristics by Treatment Approach (Operative vs Nonoperative).
| Characteristic | Operative (n = 164) | Nonoperative (n = 162) | P value |
|---|---|---|---|
| No. (%) or mean (SD) | No. (%) or mean (SD) | ||
| Age, y | 72 (7) | 71 (13) | .18 |
| Body mass index (n = 291) | 26 (4) | 27 (6) | .08 |
| Sex | |||
| Woman | 141 (86) | 133 (82) | |
| Man | 23 (14) | 29 (18) | |
| Smoking history | .05 | ||
| Never | 108 (66) | 109 (67) | |
| Current | 3 (1.8) | 11 (6.8) | |
| Prior | 53 (32) | 42 (26) | |
| Hand dominance | .06 | ||
| Right | 128 (78) | 142 (88) | |
| Left | 13 (7.9) | 9 (5.6) | |
| Unknown | 23 (14) | 11 (6.8) | |
| Side of injury | .55 | ||
| Right | 77 (47) | 85 (52) | |
| Left | 85 (52) | 74 (46) | |
| Bilateral | 2 (1.2) | 3 (1.9) | |
| Fall from height? | <.001 | ||
| Yes | 52 (32) | 139 (86) | |
| No | 112 (68) | 23 (14) | |
| Charlson Comorbidity Index | 3.9 (2.0) | 4.3 (2.2) | .06 |
| Level of independence at time of injury | .49 | ||
| Complete independence | 132 (80) | 122 (75) | |
| Modified independence | 19 (12) | 29 (18) | |
| Modified assistance | 6 (3.7) | 5 (3.1) | |
| Complete dependence | 2 (1.2) | 3 (1.9) | |
| Unknown | 5 (3.0) | 3 (1.9) | |
| Activity level prior to injury | .77 | ||
| Active | 104 (63) | 96 (59) | |
| Moderately active | 49 (30) | 57 (35) | |
| Inactive | 6 (3.7) | 5 (3.1) | |
| Unknown | 5 (3.0) | 4 (2.5) | |
| Prior fragility fracture? | .14 | ||
| Yes | 140 (85) | 147 (91) | |
| No | 24 (15) | 15 (9.3) | |
| Presenting dorsal tilt, deg (n = 304) | 24 (12) | 13 (10) | <.001 |
| AO Classification (operative: n = 156; nonoperative: n = 159) | <.001 | ||
| A | 48 (31) | 92 (58) | |
| B | 36 (23) | 41 (26) | |
| C | 72 (46) | 26 (16) | |
In multivariable logistic regression, 2 factors were independently associated with operative treatment: increasing dorsal tilt (OR, 1.09; 95% CI, 1.05-1.12; P < .001) and AO Classification type C fractures (OR, 5.42; 95% CI, 2.35-11.61; P < .001). Increasing CCI was the only factor independently associated with nonoperative management (OR, 0.84; 95% CI, 0.72-0.997; P = .046). Activity level prior to injury and level of independence prior to injury did not predict the type of management (Table 3).
Table 3.
Logistic Regression Analysis: Variables Associated With Increased/Decreased Odds of Operative Management.
| Characteristic | Pseudo-R2 | 0.25 |
|---|---|---|
| Odds ratio (95% CI) | P value | |
| Age, years | 1.00 (0.97-1.04) | .89 |
| Body mass index | 0.97 (0.92-1.02) | .25 |
| Sex | ||
| Male | Ref. | |
| Female | 1.46 (0.61-3.54) | .40 |
| Smoking history | ||
| Never | Ref. | |
| Current | 0.33 (0.06-1.83) | .20 |
| Prior | 1.67 (0.87-3.22) | .13 |
| Charlson Comorbidity Index | 0.84 (0.72-0.997) | .046 |
| Level of independence at time of injury | ||
| Complete independence | Ref. | |
| Modified independence | 0.62 (0.23-1.70) | |
| Modified assistance | 2.34 (0.25-21.71) | .45 |
| Complete dependence | 0.40 (0.03-5.09) | .48 |
| Activity level prior to injury | ||
| Active | Ref. | |
| Moderately active | 0.68 (0.33-1.41) | .30 |
| Inactive | 1.61 (0.20-13.05) | .66 |
| Prior fragility fracture | 0.87 (0.35-2.19) | .77 |
| Presenting dorsal tilt, deg | 1.09 (1.05-1.12) | <.001 |
| AO Classification | ||
| A | Ref. | |
| B | 1.35 (0.65-2.82) | .43 |
| C | 5.42 (2.53-11.61) | <.001 |
Note. CI = confidence interval.
Discussion
The treatment of DRFs in patients aged >65 years is controversial and a subject of significant attention in the literature. In a younger population, it is well established that restoration of anatomical alignment and articular congruity leads to the best functional outcome.16,17 However, when examining older patients, there have been several studies that advocate for nonoperative management reporting equivalent functional outcomes regardless of the radiographic outcome and a higher complication rate with operative treatment.6,7,12,13,18
Arora et al in a prospective randomized trial comparing nonoperative treatment with volar locked plating in patients aged ≥65 years reported no difference in range of motion, pain, and outcomes scores at 12-month follow-up, although the operatively treated group did have better grip strength throughout the follow-up period. Achieving anatomical reduction did not have an effect on range of motion or Disabilities of the Arm, Shoulder, and Hand (DASH) scores. 7
More recent literature contradicts this earlier work showing operative treatment can result in superior radiographic and functional outcomes in elderly patients.7,11,14,19 Martinez-Mendez et al performed a randomized prospective study comparing casting versus volar plating in patients aged >60 years. They found that DASH score and pain were significantly better after volar plate fixation. When examining the impact of radiographic result on clinical outcome, they found that restoration of the articular surface, radial inclination, and ulnar variance had a positive effect on outcome. 14 Similar results were found in the randomized controlled trial performed by Saving et al. 9
In the setting of this conflicting evidence, 2013 American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines (CPG) are “unable to recommend for or against operative treatment for patients over age 55 with distal radius fractures.” 20 Several studies have examined surgeon adherence to AAOS appropriate use criteria (AUC) in DRFs. Kyriakedes et al found that actual management matched AUC recommendations 50% of the time for AO type C fractures in patients of all ages among orthopedic hand surgeons at a single level 1 trauma center. Increasing patient age was significantly associated with nonoperative treatment. Decision for operative treatment matched AUC recommendations 97% of the time, whereas decision for nonoperative treatment matched AUC recommendations only 40% of the time. 21 These findings indicate that there may be a bias among surgeons to treat DRFs in patients aged >65 years nonoperatively based on older literature. A recently published study by Giladi et al 22 demonstrated that adherence to AAOS radiographic CPG criteria resulted in improved QuickDASH scores and lower costs. While we do not have a specific age-defined criteria at our institution for acceptable alignment, we do accept a higher degree of displacement, specifically dorsal tilt and radial shortening, in elderly patients. In the shared decision-making process, these factors and the defined acceptable criteria for younger patients are discussed with the patient before making a treatment decision.
In real-time clinical practice, treatment choice for these patients is often a collaborative decision between the surgeon and the patient, taking into account fracture morphology and individual patient factors. More severe fracture displacement, as defined by several different parameters, has been cited as an indication for operative treatment.23,24 Patient factors such as age, comorbidities, smoking status, handedness, level of independence, and activity level also influence treatment choice. Our study found that the decision to proceed with surgery was largely based on radiographic factors, including increasing dorsal tilt and fracture severity. In contrast, the decision not to operate was influenced by the patient-specific characteristic CCI.
Increasing preoperative dorsal tilt showed a statistically significant albeit modest (OR, 1.09) predictive value for operative management. For every degree worsening of dorsal tilt beyond neutral, there was a 9% increase in the odds of a patient undergoing operative management. This indicates that surgeons and patients do consider dorsal tilt when deciding operative treatment, but more severe dorsal tilt alone is not strongly predictive of operative intervention. AO type C fractures had a larger (OR, 5.42) association with undergoing operative fixation. This finding is consistent with prior literature showing an association between fracture severity and operative intervention.23,25
The CCI was the only variable independently associated with nonoperative management. This is partly in agreement with prior work suggesting that patient factors be taken into consideration when selecting treatment for DRFs. In their study of patients aged >50 years, Kodama et al identified factors that predict treatment outcome and provide a treatment algorithm. They suggest an initial scoring system based on fracture characteristics on postreduction radiographs. If the fracture-specific score is above 2 points, then a secondary scoring system that includes hand dominance, occupational and recreational activity, and age (50-60 vs 60-75 vs >75) is undertaken to guide treatment. They designate additional factors (American Society of Anesthesiologists score, living situation, and activities of daily living independence) as ones that should be taken into account but not formally scored. 25 However, in our cohort, patient independence, BMI, and smoking history did not independently predict operative management. Recent literature has demonstrated that even obese patients and smokers can achieve excellent outcomes after open reduction internal fixation for DRF, 26 suggesting that BMI should not be an independent predictor of operative intervention.
Interestingly, a patient’s level of independence and activity level prior to injury did not seem to influence treatment in our study group; this may be due to the small number of patients in the inactive and complete dependence cohorts. This unexpected result may be also due to the difficulty in adequately estimating a patient’s true level of activity and independence. The low number in these groups may be a result of patients’ bias when assessing their own level of activity and dependence. Indeed, there is no widely accepted standardized scoring system to allow a reliable assessment. We believe future research should focus on establishing a better way to assess overall functional status and independence.
This study has several important limitations. It is a retrospective database study at a single institution. Although the intent is for all DRFs in patients aged >65 years to be included in the database, some cases may have been excluded unintentionally. Furthermore, patient socioeconomic status, education level, or insurance status was not included in our database, so we were unable to include these important factors in our analysis. We were also unable to include unquantifiable variables such as patient preference and bias.
Surgeon specialty and experience have been shown to contribute to treatment choice. All the surgeons in this study are members of the American Society for Surgery of the Hand (ASSH). In a 2007 review, Medicare patients who are seen by a member of the ASSH are 2.8 times more likely to receive surgical treatment. 27 In addition to specialty, years in practice have a significant effect as well, with surgeons less than 10 years out of residency being more likely to choose operative treatment. 28 Our practice, consisting of 3 early to mid-career hand surgeons, may thus have a higher rate of operative treatment for DRF than others in the region or country. We were also unable to assess how patient preferences impacted treatment choice. Nasser et al surveyed patients from the Wrist and Radius Injury Surgical Trial (WRIST) study group and found that patients often prefer operative intervention with volar locked plating. Reasons cited for this treatment preference include a quicker return to normal activity, maintenance of independence, and aesthetic concerns. 29
Finally, we did not use a standardized scoring system for activity level or independence, relying instead on the treating surgeon’s assessment and introducing a potential source of bias. However, this parallels clinical practice where surgeons often make treatment decisions based on their subjective impression of the patient. In addition, this study evaluated only the treatment chosen, not treatment outcome. The outcome of DRF management in patients aged >65 years is beyond the purpose of this research and has been evaluated elsewhere.
In conclusion, we found that fracture severity (increasing dorsal tilt and AO type C fractures) is a strong driver in the decision to pursue operative management in patients aged >65 years, whereas increasing CCI predicts nonoperative treatment. Future qualitative research focusing on the decision-making process by the patient and surgeon would be invaluable in further informing our treatment algorithms.
Footnotes
Ethical Approval: This study was approved by our institutional review board.
Statement of Human and Animals Rights: This article does not contain any studies with human or animal subjects.
Statement of Informed Consent: No data in this study are an identifier.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: David N. Bernstein 
https://orcid.org/0000-0002-1784-3288
Bailey Ingalls
https://orcid.org/0000-0002-9586-4631
Tamara D. Rozental
https://orcid.org/0000-0002-5003-0924
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