Distal radius fractures are among the most common fractures in the body, usually occurring as a result of a fall. The radius is the most commonly broken bone in the arm. Typically, these breaks occur when a person’s fall causes them to land on outstretched hands. Among younger people, distal radius fractures may occur via car, bicycle, and skiing accidents as well as other similar situations. Older individuals are at increased risk for these fractures if they have osteoporosis. Distal radius fractures in people aged 60 and older are frequently caused by falls from a standing position. Their decreased bone density can make relatively minor falls result in broken wrists.
According to the American Academy of Orthopaedic Surgeons (AAOS), more than 261,000 emergency room visits in 2007 were caused by distal radius fractures. “These fractures are most commonly seen and treated in emergency departments, but follow-up of these patients is typically performed by primary care providers and orthopedic surgeons,” explains David M. Lichtman, MD. “Currently, there are many treatment options for managing patients with distal radius fractures, ranging from less invasive methods, such as cast treatment, to more invasive techniques, such as fixation devices. Physicians are often challenged by treatment decisions because there is relatively little evidence-based information to guide them along the way.”
A Deeper Look at the Evidence
In December 2009, the AAOS approved and released an evidence-based clinical practice guideline on the treatment of distal radius fractures. Available at http://www.aaos.org, it analyzed over 4,000 journal articles from around the world over 1 year. Each article was graded on a 5-point scale depending on strength and quality of evidence. To earn the highest grade (meaning it had strong evidence), studies had to fulfill the criteria of being prospective, randomly controlled clinical trials with enough patients to establish clinical and statistical significance. The results had to be determined using validated, patient-oriented outcome measurement tools.
These guidelines can serve as a point of reference and an educational tool for primary care physicians and orthopedic surgeons,” says Dr. Lichtman, who chaired the work group that created the guideline. “Our goal was to streamline possible treatment processes for this common problem. There are a wide range of treatment options available. As such, it’s important to tailor these strategies to individual patients based on their characteristics after they’ve had discussions with orthopaedic surgeons.”
“More data is clearly needed to bolster our knowledge and steer physicians in making the most appropriate treatment decisions.”
— David M. Lichtman, MD
The AAOS guidelines for treating distal radius fractures are outcomes-oriented and contain 29 evidence-based recommendations overall, several of which are significant. An important recommendation that emerged was that rigid casting appears to be better than splinting if fractures were displaced. When fractures are not displaced (eg, a hairline crack), removable splints can be worn. Surgery should be considered in fractures that have a tendency to fall back to their original position following reduction because it appears that surgery permits these fractures to heal in better functional alignment than when treated in a cast.
“The evidence-based recommendations for distal radius fractures are categorized as consensus, moderate, and weak,” Dr. Lichtman says (Figure 1). “The consensus recommendations are more anecdotal than evidence-based, but they’ve been made based on a large collection of experience. The consensus recommendation was used only when the work group felt that a recommendation was needed but there was not strong enough evidence to support a higher grade. Moderate recommendations have more evidence-based support, while weak recommendations are those where less reliable evidence exists across all literature. Regardless of category, an important point revealed by these guidelines is that more data are clearly needed to bolster our knowledge and steer physicians in making the most appropriate treatment decisions.”
Key Questions Remain
According to the AAOS work group, one key question that needs to be answered in future research is whether surgeons should perform the same operations and use the same fixation methods with older patients as they do with younger patients (Figure 2). “Treatment is not ‘one size fits all’ because patients present in various ways with varying characteristics and types of breaks,” says Dr. Lichtman. For example, some elderly patients are physiologically younger than others. By lifting weights, exercising regularly, and keeping in shape, some seniors can achieve the same bone structure of people who are 20 or 30 years younger. “The recommendations for distal radius fractures aren’t a finished product,” says Dr. Lichtman. “During our review of the literature, it was surprising to find that there are currently no answers to many of the questions physicians are likely to ask. It’s hoped that the guidelines can serve as a springboard for more research, especially prospective, randomized control studies that compare specific treatments among patients with similar characteristics. Furthermore, it will behoove researchers to conduct more long-term, multi-centered investigations and meta-analyses that explore which treatments work best under different clinical circumstances.”
American Academy of Orthopaedic Surgeons. The Treatment of Distal Radius Fractures: Guidelines and Evidence Report, December 5, 2009. Available at: http://www.aaos.org/Research/guidelines/drfsummary.pdf.
Fanuele J, Koval KJ, Lurie J, Zhou W, Tosteson A, Ring D. Distal radial fracture treatment: what you get may depend on your age and address. J Bone Joint Surg Am. 2009;91:1313-1319.
Karnezis IA. Treatment and complications of distal radius fractures. Minerva Ortopedica e Traumatologica. 2005;56:393-410.
Kawamura K, Chung KC. Management of wrist injuries. Plastic Reconstruct Surg. 2007;120:73e-89e.
Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am. 2006;88:1944-1951.
Raia FJ, Catalano III LW. What’s new in distal radius fracture treatment for 2007. Current Opinion Orthopaedics. 2007;18:328-333.