Keywords
distal radius fracture - malunion - reconstructive surgery
Introduction
Distal radius fracture (DRF) was, is and will be one of the most frequent injuries
in all life stages and reason for consultation in any health center. In recent years,
specifically in Spain, the aging index has registered its historical maximum, over
120% (120 people over 64 years old for every 100 people under 16 years old). In fact,
within this elderly population, the rate of over-aging has increased due to lifestyle
and healthcare improvements.[1] These facts led to an increase in DRF cases and modified its management.
Currently, DRF in elderly patients has several peculiar aspects. Firstly, the low
bone quality associated with a high comminution degree results in fracture instability,
implying in a gradual closed reduction loss and complicating the decision-making process
([Figure 1]). Secondly, regarding orthopedic treatment, the concept that, despite a suboptimal
radiological outcome, the functional result will be favorable remains valid.[2] Thirdly, when the patient finally is evaluated by a hand surgery specialist (often
more than 2 weeks after trauma), the literature supporting surgical treatment in “partially
misaligned fractures” is scarce.
Fig. 1 Example of radial fracture and unstable distal ulna. (A) Initial fracture. (B) Closed
reduction. (C). Radiological parameters worsening after 3 weeks. (D) Definitive treatment.
The purpose of this study was to evaluate radiological and functional outcomes of
delayed surgical treatment in elderly patients with DRF. The hypothesis was that fracture
anatomical and stable reconstruction offers satisfactory results, similar to those
observed in other age groups.
Material and Methods
Study Population
All patients referred to the Hand Surgery Unit for surgical treatment of DRF from
September 2015 to June 2018 were reviewed. Inclusion criteria were patients older
than 70 years old with a DRF with three to six weeks of evolution. Exclusion criteria
were patients outside the previously established age and evolution range, active infection,
sequelae of previous fracture or complete fracture consolidation. A group of 31 patients
(27 women and 4 men) with a mean age of 76 years old (range, 70-91) constituted the
study population. There were no losses at follow-up.
Clinical Design
This was a retrospective study with initial patient assessment and follow-up by two
hand surgery experts. A preoperative evaluation was carried out to collect sociodemographic
data and determine relevant medical history, comorbidities and autonomy degree. Radiographs
were serially evaluated, including images from the initial fracture and those obtained
after reduction (performed at the emergency room), postoperatively and at the end
of follow-up period. Fractures were classified according to Fernández.[3] Radial inclination, volar tilt, ulnar variance, and joint gap were measured before
and after surgery. Radiological analysis consisted in comparison with normal values
described in the literature.[4] Functional outcomes were evaluated according to the Mayo Wrist Score[5] at the end of the follow-up period. At the surgical technique level, the performance
of arthroscopy, the use of a bone graft and the treatment of associated ulnar fractures
were analyzed. Lastly, postoperative complications were assessed.
Indication and Surgical Technique
All patients were evaluated preoperatively by orthopedic surgeons specialized in hand
pathology. Surgical treatment indication was based on a detailed study of comorbidities
in patients with adequate physical and cognitive status. The following radiological
criteria were applied for surgical treatment indication: dorsal angulation higher
than 20°, radiocarpal subluxation, joint gap higher than 2 mm and ulnar variance higher
than 2 mm secondary to radial fracture focus shortening.[6] All therapeutic possibilities, with their respective advantages and disadvantages,
were explained to the patient, allowing him to choose the definitive treatment option.
All patients signed an informed consent form for joint fracture reconstructive surgery
and wrist arthroscopy.
Under axillary block and using a proximal ischemia cuff in the arm, an osteosynthesis
with volar plate was performed following the guidelines described by Orbay.[7] Since surgical treatment was delayed, the fibro-osseous tissue at the fracture (volar
and dorsal) focus had to be removed using a bone curette and gouge forceps. Particularities
of surgical treatment regarding an acute fracture included the extended approach with
complete diaphyseal pronation for fibrotic tissue debridement and dorsal fragments
reduction, the use of a Hintermann distractor at fracture focus to restore the radio-ulnar
relationship at the frontal plane, the use of an anatomical plate to restore fracture
angulation and the use of arthroscopy as a tool to remove the interposed tissue at
the articular level and check the reduction ([Figure 2]). The ulnar edge of radius reconstruction was used as a reference for fracture reduction[8] and volar angulation was restored using an anatomical plate with cortical screws.
Reduction and initial fixation were checked routinely with fluoroscopy; arthroscopy
using 3/4 and 6R portals, 5 kg of zenith traction, elbow flexed at 90° and forearm
in neutral position was performed in cases with persistence of some type of joint
gap after reduction maneuvers remained or doubts regarding the presence of intra-articular
osteosynthesis material. Arthroscopic evaluation was not performed in cases with a
satisfactory reduction intraoperatively and good stability provided by the osteosynthesis
material. Lastly, fixation was completed with angular stability screws, definitive
arthroscopic verification and closure by planes.
Fig. 2 Distractor application at fracture site to restore the radio-ulnar relationship in
fractures with severe shortening.
Postoperative Period
After the procedure, a plaster dorsal splint was used for two weeks, followed by rehabilitation
therapy and comfort orthoses until approximately the sixth week depending on fracture
type. Per protocol clinical-radiological controls were performed at 2 weeks, 6 weeks,
3 months, 6 months and 12 months. At the end of the follow-up period, the Mayo Wrist
Score was evaluated, and revisit guidelines were delivered.
Statistical Analysis
Data was analyzed using the SPSS statistical package (SPSS Inc, Chicago) version 25.0.
For quantitative variables, mean and standard deviation (SD) values were used; for
qualitative variables, numbers and percentages were used. Radiological data and postoperative
functional outcomes were analyzed using the Chi-square test considering a 95% level
of statistical significance (p < 0.05).
Results
In total, 31 patients (27 females and 4 males) underwent volar plate osteosynthesis;
fracture consolidation was achieved in all of them. Mean age was 76 years old (range,
70-91). Median delay time until intervention was 22 days (range, 15-49). Mean postoperative
follow-up time was 17 months (SD, 9.6). Fourteen cases (45.2%) presented ulnar fractures,
mostly with styloid avulsion, in which osteosynthesis was not performed, except for
three cases requiring plate stabilization due to metaphyseal-diaphyseal involvement.
According to the Fernández classification, 11 cases (35.5%) were classified as type
I, 4 cases as type II (12.9%), 12 cases as type III (38.7%) and 4 cases as type IV
(12.9%); there was no type V cases. Initial reduction was satisfactory in 17 cases
(54.8%). At the preoperative radiological study, a radial inclination of 16.87° (SD,
5.9), a cubital variance of 3.54 mm (SD, 2.99), a dorsal angulation of 15.8° (SD,
14.7) and a joint gap of 1.74 mm (SD, 2.3 mm) were observed. The postoperative radiological
study showed a statistically significant correction of joint gap, radial inclination
and ulnar variance, with the following measurements: radial inclination of 23.99°
(SD, 4.5) (p 0.05), ulnar variance of 0.97 mm (SD, 1.5) (p 0.00), joint gap of 0.1 mm (SD, 0.3) (p 0.01). No statistically significant improvement in angle correction was been obtained,
with a mean volar tilt of 1.74°° (SD, 6.02) (p 0.053). During surgery, arthroscopic assistance was used in 17 cases (54.8%), and a bone
graft was employed as a structural support due to a metaphyseal defect in four cases
(12.9%).
Functional outcomes included an average score of 81.94 (SD, 10.46), classified as
“good” according to the Mayo Wrist Score system. No statistically significant correlation
with the fracture pattern or arthroscopic assistance was observed. There were no intraoperative
complications, but postoperative complications were observed in four cases (12.9%):
a joint protrusion of the screw, two cases of distal screw loosening and one case
of flexor pollicis longus tendon rupture 2 years after the intervention. Nine cases
(29%) presented pseudoarthrosis of the ulnar styloid base; however, since the patients
were clinically asymptomatic and did not require salvage surgical treatment, these
were not counted as complications ([Table 1]).
Table 1
|
Patient
|
Gender
|
Follow-up
|
Age (years)
|
Fernández Classification
|
Delay IQ
(weeks)
|
Complications
|
Mayo Wrist Score
|
Preop tilt
|
Preop radial inclination
|
Preop variance
|
Preop joint gap
|
Postop tilt
|
Post op radial inclination
|
Postop variance
|
Postop joint gap
|
|
1
|
Male
|
36
|
91
|
IV
|
2
|
No
|
90
|
-18
|
23
|
2
|
3
|
3
|
23
|
0
|
No
|
|
2
|
Male
|
36
|
70
|
III
|
2
|
Screw loosening
|
70
|
-18
|
20
|
0
|
6
|
-4
|
21
|
0
|
1
|
|
3
|
Female
|
30
|
70
|
III
|
2
|
Intraarticular screw
|
75
|
-10
|
19
|
0
|
0
|
0
|
16
|
0
|
No
|
|
4
|
Female
|
30
|
72
|
II
|
2
|
No
|
90
|
-2
|
26
|
0
|
9
|
10
|
29
|
0
|
No
|
|
5
|
Female
|
29
|
86
|
III
|
2
|
No
|
75
|
-2
|
20
|
6
|
0
|
0
|
25
|
2
|
No
|
|
6
|
Female
|
28
|
90
|
II
|
3
|
No
|
80
|
40
|
18
|
8
|
7
|
5
|
28
|
-1
|
1
|
|
7
|
Female
|
28
|
73
|
I
|
2
|
No
|
95
|
-30
|
17
|
1
|
0
|
-5
|
20
|
0
|
No
|
|
8
|
Female
|
27
|
75
|
IV
|
2
|
No
|
100
|
-38
|
12
|
5
|
4
|
-9
|
25
|
0
|
No
|
|
9
|
Female
|
23
|
85
|
I
|
3
|
No
|
100
|
7
|
25
|
8
|
0
|
7
|
27
|
2
|
No
|
|
10
|
Female
|
21
|
73
|
II
|
3
|
No
|
100
|
0
|
21
|
6
|
1
|
1
|
25
|
3
|
No
|
|
11
|
Female
|
22
|
76
|
III
|
3
|
No
|
90
|
-20
|
17
|
4
|
2
|
9
|
23
|
2
|
No
|
|
12
|
Female
|
21
|
71
|
III
|
4
|
No
|
70
|
-3
|
5
|
5
|
1
|
0
|
24
|
0
|
No
|
|
13
|
Female
|
21
|
79
|
I
|
4
|
No
|
85
|
-14
|
22
|
2
|
0
|
-10
|
20
|
0
|
No
|
|
14
|
Female
|
21
|
72
|
IV
|
4
|
No
|
70
|
-13
|
17
|
2
|
2
|
0
|
29
|
-1
|
1
|
|
15
|
Female
|
17
|
72
|
III
|
6
|
No
|
90
|
-3
|
17
|
6
|
1
|
0
|
25
|
2
|
No
|
|
16
|
Female
|
15
|
78
|
III
|
4
|
No
|
80
|
-5
|
18
|
0
|
1
|
3
|
30
|
0
|
No
|
|
17
|
Female
|
15
|
72
|
II
|
7
|
No
|
65
|
-6
|
17
|
0
|
3
|
6
|
23
|
0
|
No
|
|
18
|
Female
|
14
|
75
|
I
|
2
|
No
|
75
|
-17
|
20
|
3
|
0
|
2
|
25
|
0
|
No
|
|
19
|
Female
|
11
|
70
|
I
|
3
|
No
|
85
|
5
|
10
|
8
|
0
|
2
|
29
|
5
|
No
|
|
20
|
Female
|
10
|
74
|
III
|
2
|
No
|
75
|
-14
|
20
|
0
|
2
|
-9
|
27
|
0
|
No
|
|
21
|
Male
|
12
|
80
|
III
|
4
|
No
|
65
|
-3
|
21
|
0
|
4
|
-3
|
24
|
0
|
No
|
|
22
|
Male
|
10
|
70
|
I
|
3
|
No
|
70
|
5
|
19
|
6
|
0
|
10
|
25
|
3
|
No
|
|
23
|
Female
|
9
|
72
|
I
|
2
|
No
|
80
|
-13
|
17
|
3
|
0
|
12
|
25
|
2
|
No
|
|
24
|
Female
|
9
|
70
|
I
|
2
|
Flexor pollicis longus tendon rupture
|
100
|
0
|
23
|
2
|
0
|
10
|
25
|
0
|
No
|
|
25
|
Female
|
8
|
85
|
I
|
2
|
No
|
85
|
0
|
3
|
6
|
0
|
5
|
12
|
5
|
No
|
|
26
|
Female
|
6
|
78
|
I
|
4
|
No
|
80
|
30
|
0
|
4
|
0
|
0
|
15
|
0
|
No
|
|
27
|
Female
|
6
|
73
|
I
|
4
|
No
|
90
|
-3
|
14
|
4
|
0
|
0
|
21
|
2
|
No
|
|
28
|
Female
|
6
|
88
|
IV
|
5
|
No
|
75
|
23
|
15
|
11
|
0
|
9
|
16
|
3
|
No
|
|
29
|
Female
|
6
|
73
|
III
|
4
|
No
|
75
|
-19
|
14
|
0
|
3
|
2
|
24
|
0
|
No
|
|
30
|
Female
|
6
|
77
|
III
|
4
|
No
|
80
|
-8
|
20
|
5
|
5
|
6
|
28
|
0
|
No
|
|
31
|
Female
|
6
|
75
|
III
|
3
|
Screw loosening
|
80
|
3
|
13
|
3
|
0
|
-8
|
16
|
1
|
No
|
Discussion
Firstly, this study describes the functional and radiological outcomes of the delayed
surgical treatment of DRF in a specific population. Secondly, some particularities
considered to achieve anatomical reconstruction and fixed fragment stability are described
at a technical level. Thirdly, results analysis suggests a relationship between anatomical
reconstruction and satisfactory functional outcome; however, the hypothesis cannot
be confirmed due to sample size and the retrospective design of the study.
There is abundant medical literature on DRF management. Due to its high frequency,
different professionals can participate in its treatment, including emergency physicians,
traumatologists, hand surgeons, rehabilitators and physical therapists. In addition,
this is an injury with a high degree of displacement and re-displacement, specifically
30% during the first 10 days and 29% more 10 to 20 days after the fracture.[9] Despite its frequency, there is strikingly little literature on surgical treatment
in cases partial misaligned consolidation in elderly patients with good functional
and cognitive features. As such, this type of patient needs to be identified and assessed
both in a multidisciplinary and specialized way.
The main controversy in the management of this type of injury is that, currently,
on the one hand, there is literature supporting orthopedic treatment despite a non-anatomical
reduction and/or clinical deformity,[10]
[11] especially in elderly patients. On the other hand, there is also literature[12] indicating that DRF malunion results in loss of function in the upper limb, even
2 years after fracture and considering surgical treatment benefits[.11] This difference of opinion is probably due to several aspects, including lack of
specificity of assessment instruments, samples heterogeneity and study designs. In
this age group, loss of upper limb function has a greater impact on quality of life,
since most daily activities require using the hands.[13] Therefore, efforts must be focused on narrowing the surgical indication. First of
all, regarding quality of life, a patient who lives alone and performs all daily activities
with no help from others (for example, going to the doctor's office) must be considered
an active individual. Second, regarding the need for reconstructive surgery, the goal
is to achieve a reduction as close as possible to normal anatomy. The main parameters
are volar angulation, radial height, and radiocarpal and radioulnar joint relationships
restoration, with acceptable displacement limits of 20° for dorsal deformity, less
than 3 mm for joint step and < 3 mm for ulnar plus; in addition, unstable patterns
that may result in joint subdislocation must be avoided[14] (dorsal or volar Barton fracture).
Obviously, from the surgical point of view, the best time to treat a fracture is within
the first days after its occurrence. It has been described that, as early as 2 weeks,
a fibrous callus formation makes treatment difficult.[7] Therefore, to avoid the development of a reflex sympathetic dystrophy, surgical
treatment must be indicated as soon as an intolerable displacement is detected to
obtain a faster recovery. Even so, the medical literature describes that there were
no differences in DASH scores from patients younger than 55 years old who underwent
surgery for DRF either at approximately 8 or 30 days after trauma.[15] A fracture with several weeks of evolution must be treated through a soft tissue
approach and release for correct reduction. Although it is not the purpose of this
study, arthroscopy was deemed useful to remove the fibrotic tissue located in the
fracture focus at the radiocarpal joint facet level, with fragments manipulation with
a Freer-type dissector and synoviotome[16] ([Figure 3]); this allows for a fine articular reduction and checks osteosynthesis stability.
In contrast to acute management, the use of bone grafts in cases of large metaphyseal
defects must be considered, as required in four cases from our series. The literature
describes the use of bone substitutes with satisfactory clinical-radiological results.[17]
Fig. 3 Images of arthroscopic treatment (fibrotic tissue debridement) using a synoviotome.
Regarding the functional outcome of DRF surgical treatment, the literature indicates
that fixed angle locked volar plates have good results in elderly patients regardless
of the assessment instrument,[18] with 85% of good outcomes and a 8% rate of complications one year after surgery.
Jupiter[6] described excellent outcomes in 18 from 20 patients older than 60 years old treated
for DRF, with 15% of complications. In our series, functional outcomes were similar,
with 12.9% of complications, consisted with data published so far, even with younger
populations and shorter evolution times. Therefore, these data invite reconstructive
surgery to be considered despite the fact that it is not the best scenario for the
surgeon; a satisfactory outcome is expected with no increase in complication rates.
There are other fixation methods, including Kischner wires and/or external fixators,[19]
[20] reportedly with favorable outcomes, but with an irregular complication rate, ranging
from 15% to 45%.
We conclude that the delayed surgical treatment of DRF in elderly patients offers
similar results to those observed in other age groups and different times of evolution.
The appropriate surgical indication for these patients is really important; despite
not being the ideal setting for the surgeon, it must be considered to avoid functional
deterioration in this fragile age group.
Limitations of this study included its retrospective design and the absence of a control
group, not allowing the determination of which is the best treatment for a condition
that, unfortunately, will be increasingly frequent. Therefore, considering outcomes
from surgical treatment, it would be appropriate to propose studies with a higher
level of evidence, even of a multicentric nature, to clarify the optimal management
of elderly patients with unstable distal radial fractures.
