Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Charles S. Day, MD, MBA, and Eric C. Makhni, BS*,
Beth Israel Deaconess Medical Center, Boston, Massachusetts
Posted June 2009
The study entitled "Distal Radial Fracture Treatment: What You
Get May Depend on Your Age and Address," by Fanuele et al., explores epidemiologic
factors associated with the incidence and the management of distal radial
fractures in the Medicare patient population. More than 100,000 distal radial
fractures were retrospectively assessed from 1998 through 2004, comprising a
20% sample of Medicare Part-B claims. Relevant demographic and clinical
information for each patient included age, sex, geographical location, and type
of treatment received. Treatment type was categorized as either nonoperative
(i.e. closed reduction with a cast) or operative (external or percutaneous fixation,
or open reduction and internal fixation). Moreover, the authors hypothesized
that the rates of the various treatment types would vary by geographical region.
Fanuele et al. did indeed discover significant variation in
the incidence and rates of various treatment modalities according to patient demographics
and geography. In addition to being correlated with female sex, white race, and
advanced age, increased fracture incidence was also associated with residence in
the eastern part of the country. Moreover, depending on geographical region, rates
of nonoperative treatment ranged from 60% to 96%, while those of percutaneous fixation
and open reduction and internal fixation ranged from 2% to 39% and 0.4% to 25%,
respectively. The authors attributed this range in treatment patterns to a lack
of consensus regarding optimal treatment techniques as well as inherent
geographically based cultural differences and variations in the acceptance of findings
reported in the literature. Furthermore, the study found that rates of nonoperative
fixation increased with increasing patient age; specifically, patients who were
within the range of sixty-five to sixty-nine years of age were treated nonoperatively
78% of the time, and those who were eighty-five years of age or older were
treated nonoperatively 91% of the time. Finally, the authors noted that overall
rates of operative treatment in the Medicare patient population remained
relatively constant throughout the study period (1998 through 2004), at
approximately 16% nationwide. However, rates of open reduction and internal
fixation increased over the period, from 4% to 8%, while rates of percutaneous fixation
decreased from 12% to 9%.
The results of this study raise several important points of
discussion. While the association between distal radial fracture risk and
certain demographic characteristics (advanced age, female sex, and white race)
has been previously established, the relationship between geographical region
and incidence discovered in this study is surprising.
One might assume that colder regions, being more prone to
icy conditions, would be associated with higher rates of fracture. However, Fanuele
et al. reported an increased fracture incidence in areas of the eastern United
States that do not appear to be climate dependent. The explanation of this
finding requires further investigation.
A second point of discussion is that, despite the high prevalence
of distal radial fractures in the older population, the optimal method of
managing this injury has yet to be determined. Several studies have shown that
operative fixation—especially open reduction and internal fixation—results in
better anatomical alignment when compared with that obtained with use of more
conservative approaches. Why, then, is open reduction and internal fixation not
overwhelmingly the treatment of choice? One argument against using open
reduction and internal fixation more frequently is the appreciable risk of complications
associated with open reduction and internal fixation1-3. More
importantly, a definitive relationship between final anatomical alignment and
functional outcomes in older patients has yet to be established. (In young
patients, however, it has been shown that superior anatomical alignment after
fracture repair leads to improved functional outcomes4.) Some
earlier studies suggest such a correlation exists regardless of age5,
while more recent papers indicate little correlation between anatomical
alignment and good functional outcomes6-8. Without conclusive
evidence for or against a relationship between anatomic alignment and
functional outcomes, a standardized treatment algorithm for these patients
cannot be provided; thus, treatment types vary widely across the country for
the same patient population.
Another interesting finding of this study is the increased
use of open reduction and/or internal fixation when compared with percutaneous fixation
and/or external fixation. In a study of orthopaedic surgeons who were taking American
Board of Orthopaedic Surgery (ABOS) oral (Part II) examinations, Koval et al.
reported that the proportion of fractures that were stabilized with open
reduction and internal fixation among operative distal radial fracture patients
increased from 42% in 1999 to 81% in 2007, while rates of percutaneous fixation
dropped from 58% to 19% during the same period9. One possible
explanation for these results is the recent rise in popularity of volar
(locked) plate fixation, even in the elderly population10. However, the
results of recent studies have challenged the notion that volar plate fixation
provides superior functional outcomes when compared with that provided by
external fixation11,12, and it has been reported in other studies
that the complication rates of volar plating can range from 20% to 50%1-3.
It will be interesting to see if the current trend of plate fixation of distal
radial fractures will continue.
One of the major strengths of the paper by Fanuele et al. is
the size of the study cohort. Using national Medicare data, the authors were
able to report both the incidence of distal radial fractures and the rates of operative
versus nonoperative treatment in this wide sample of patients. This study is
among the largest to demonstrate these epidemiologic factors; however, the
authors did acknowledge certain limitations inherent in a study of this nature.
For example, they relied on coded information, which may not be as accurate as information
collected from original operative reports. Moreover, radiographic data were not
assessed. Therefore, we cannot be certain that the trends in treatment
frequency (i.e., increasing use of open reduction and internal fixation over
time) were due to subjective rather than objective (radiographic) findings or
that the types of fractures did not change over time. Finally, it would have
been helpful to see more detailed results, such as changes in treatment rates
over time within each demographic group (i.e., treatment rates per year within
each age group or geographic region).
Based on the findings of Fanuele et al., there are now
several important questions that must be addressed as we go forward. The
authors have provided information regarding rates of operative treatment among an
older population with distal radial fractures; however, how do these rates
compare with those of a younger but otherwise similar population? An answer to
this question would allow a determination to be made about whether or not
inherent treatment biases already exist with regard to patient age. A second
important question to consider is: What is the most effective treatment
strategy for older patients with distal radial fractures? The radiographic
presentation of these fractures typically guides a surgeon's decision-making
process in determining the most appropriate form of fixation. At this time,
however, there exists no definitive set of radiographic parameters—tailored to
the elderly patient population—that can be used to determine the most
appropriate treatment modality. To answer the above question, we must first
determine if a relationship exists between radiographic and functional outcomes
in this older patient population. If there is no association between functional
and radiographic outcomes, perhaps conservative fixation techniques, such as
closed reduction or percutaneous fixation, would be better suited for this
older patient demographic. If a relationship between radiographic alignment and
functional outcome can be demonstrated, we will be able to provide a more
standardized treatment algorithm to older patients who have sustained a distal
radial fracture.
*The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
References
1. Arora R, Lutz M, Hennerbichler A, Krappinger D, Espen D, Gabl M. Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop Trauma. 2007;21:316-22.
2. Rozental TD, Blazar PE. Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius. J Hand Surg [Am]. 2006;31(3):359-65.
3. Yu Y, Makhni MC, Rozental TD, Mundanthanam G, Day CS. Complications of low-profile dorsal and volar locking plates in the distal radius: a comparative study. Unpublished data.
4. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg [Am]. 1986;68:647-59.
5. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg [Am]. 1994;19:325-40.
6. Jaremko JL, Lambert RG, Rowe BH, Johnson JA, Majumdar SR. Do radiographic indices of distal radius fracture reduction predict outcomes in older adults receiving conservative treatment? Clin Radiol. 2007;62:65-72.
7. Synn AJ, Makhni EC, Makhni MC, Rozental TD, Day CS. Distal radius fractures in older patients: is anatomic reduction necessary? Clin Orthop Relat Res. 2009;467:1612-20.
8. Arora R, Gabl M, Gschwentner M, Deml C, Krappinger D, Lutz M. A comparative study of clinical and radiologic outcomes of unstable Colles type distal radius fractures in patients older than 70 years: nonoperative treatment versus volar locking plating. J Orthop Trauma. 2009;23:237-42.
9. Koval KJ, Harrast JJ, Anglen JO, Weinstein JN. Fractures of the distal part of the radius. The evolution of practice over time. Where's the evidence? J Bone Joint Surg Am. 2008;90:1855-61.
10. Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg [Am]. 2004;29:96-102.
11. Margaliot Z, Haase SC, Kotsis SV, Kim HM, Chung KC. A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg [Am]. 2005;30:1185-99.
12. Wright TW, Horodyski M, Smith DW. Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine plate versus external fixation. J Hand Surg [Am]. 2005;30:289-99.
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