HAND AND WRIST (DA OSEI, SECTION EDITOR)
Evaluation and treatment of osetoporotic distal radius
fracture in the elderly patient
Eric M. Padegimas & Daniel A. Osei
Published online: 18 January 2013
#Springer Science+Business Media New York 2013
Abstract Distalradius fractures are anincreasinglyprevalent
upper extremity injury, especially among elderly patients.
While treatment guidelines for the acute bony injury have
been well documented, treatment of the underlying metabolic
bone disease has been less commonly discussed in the ortho-
pedic literature. Distal radius fractures in the elderly patient
should be considered a sentinel event for injuries associated
with greater morbidity and mortality, such as hip fracture.
Management of fracture-related factors, such as osteoporosis
and increased fall risk following a distal radius fracture, may
prevent the mortality and morbidity of future injuries. This
review highlights both the fracture-specific and medical goals
of treatment in the elderly patient with a distal radius fracture.
Distal radius fracture (DRF) is the most common upper
extremity fracture affecting elderly patients [63••]. With
640,000 reported DRFs in the United States in 2001, the
health and economic burden is substantial [1, 2••]. DRFs
contribute significantly to the estimated $1.1 billion cost of
osteoporotic fractures in the Medicare population [58••, 64].
For unknown reasons, the incidence of these fractures has
been on the rise both in the U.S. and globally [2••, 3, 4••, 5,
6]. Furthermore, the increase in incidence has disproportion-
ately affected patients 65 years old and older . Within this
population, DRFs account for 18 % of all fractures . This
injury is especially prominent in the active elderly, since the
common mechanism of fracture is a standing level fall
(SLF) onto a dorsally outstretched hand. As life expectancy
increases and as people continue to stay active later in life,
geriatric DRF has become an increasingly important clinical
The aim of this review is to explore the risk factors of
DRFs, as well as how they may be interpreted as a sentinel
event for other more morbid fragility fractures, such as hip or
vertebral fractures. The significance of this evaluation is two-
fold: determination of measures that may be taken to prevent
event, in order to prevent occurrence of more morbid injuries.
Patient age andgender are the twobest predictorsofDRF.The
as high as 281 per 100,000 person-years in the 8th decade of
life [12••]. The incidence in men then further increases to 466
per 100,000 in the over-80-year-old population. Women show
a significant increase in incidence after age 50 (from 169/
50 and 59). As for men, the incidence in women continues to
increase with age to a peak of 1,107/100,000 over the age of
80 years. The disproportionately high incidence in elderly
women has been corroborated by a number of studies [10,
qualitative changes in bone and decreased bone mineral den-
sity (BMD) in conjunction with an aging population that has
become increasingly active explain this epidemiological pat-
tern. Osteoporosis, defined as a BMD of −2.5 standard devia-
tions or less of peak bone mass (average of healthy, gender-
matched, young adults) and osteopenia defined as a BMD of
E. M. Padegimas:D. A. Osei (*)
Department of Orthopedic Surgery, Washington University School
of Medicine, Campus Box 8233, 660 South Euclid Avenue,
St. Louis, MO 63110, USA
Curr Rev Musculoskelet Med (2013) 6:41–46
−1.0 to −2.5 standard deviations of peak bone mass (average
factors of DRF in elderly women [15, 16, 17••, 18••, 19••,
20••]. Furthermore, decreased BMD has been found to be
predictive of severity of DRF .
In addition to BMD, the correlation between hypovitami-
nosis D and DRFs has recently been explored. The role of
vitamin D in bone mineralization, growth, and remodeling is
well-known and documented [22–24]. In a study examining
37 male patients from 30 to 75 years old with distal forearm
fractures, 49 % of these had vitamin D insufficiency, defined
as serum levels between 20 and 30 ng/mL, or deficiency,
defined as serum levels less than 20 ng/mL . Jang et al.
looked at 104 postmenopausal women treated surgically for
DRF, along with 107 age-matched controls. In the group
that sustained DRFs, 19 were vitamin D deficient, and 27
were vitamin D insufficient, while in the control group, only
2 were deficient, with 12 being insufficient (p<.001) [26••].
Furthermore, the correlation with hypovitaminosis D and
DRFs has been found to be independent of BMD [27••].
Seasonal risk factors have also been noted, with dispropor-
tionately increased incidence in the winter. In Finland, there
was a statistically significant difference between SLFs leading
to DRFs in winter (60 %) versus nonwinter (40 %), posited to
be the result of an increased fall risk with inclement weather
[12••]. Furthermore, a seasonal difference in vitamin D has
significantly lower in patients with DRFs in autumn (p=.049)
and winter (p=.001), with decreased daylight hours as well as
less time with skin exposure in the sun [26••]. The change in
difference in season-related incidence.
Goals of treatment
The primary goal of treatment is prevention offracture. While
many studies show a correlation of osteoporosis, vitamin D
deficiency, and elderly falls with DRFs, there is a paucity of
literature regarding preventative treatment of this injury pat-
tern. Maintenance of functional hand and wrist motion is
crucial for preservation of independent activities of daily
living in the elderly—specifically, in hygiene and feeding.
DRFs havealsobeenshown tobea harbinger ofhip fractures,
risk [28–31]. One study showed that women 60–79 years old
who had suffered a fracture of the distal radius had a relative
risk of 1.9 (statistically significant with a 95 % CI of 1.3–2.6)
of sustaining a hip fracture . Meta-analysis of Colles
fracture and the subsequent risk of hip fracture showed a
prospective association in both genders, with a significantly
stronger association seen in men .
Even when the hand is not directly injured, secondary
ance of hand and finger use, and nerve compression. Edema
control measures, such as early postinjury finger and hand
of tight casting or prolonged use of a sling, play an important
role . Early mobilization of the forearm at the elbow helps
restoration of preinjury (and preimmobilization) supination
after immobilization is important for eating and hygiene.
Patients often continue to have disability in wrist flexion and
extension, as well as superficial deformity; however, this rarely
has a significant functional consequence in the elderly [11, 32].
The best preventative measure for DRFs and other fragility
fractures is osteoporotic management. Current screening
guidelines for osteoporosis state that women should receive
screening with duel-energy x-ray absorptiometry (DXA) of
the hip and lumbar spine at 65 years old. This testing also
suggests that for women less than 65 years old with a 10-year
fracture, risk is equal to or greater than that of a 65-year-old
Caucasian female without additional risk factors. The United
States Preventative Services Task Force (USPSTF) does not
currently make recommendations regarding screening of men
without previous known fractures or secondary causes of
osteoporosis or recommendations on the interval for repeat
screening intervals, due to a lack of sufficient evidence .
Meta-analysis of randomized control trials show statistically
insignificant efficacy of treatment with a DXA t-score from
−1.0 to −2.5 . However, treatment of patients with a DXA
calcium supplementation weight-bearing exercise, as well as
pharmacotherapy tailored to the individual patient.
Pharmacologic options include bisphosphonates, parathyroid
hormone, raloxifene, and estrogen .
There is a paucity of literature regarding assessment of
vitamin D levels and consequent supplementation in cases of
hypovitaminosis D in primary prevention of DRFs. The
USPSTF recommends against vitamin D and calcium supple-
mentation in the general population, on the basis of the results
of the Women’s Health Initiative (WHI) [35, 36••]. The WHI
examined 36,282 healthy postmenopausal women from 50 to
79 years old and randomly assigned 400 IU of vitamin D3and
a 1.06 % increase in hip bone density in the treatment arm
(p<.01) but a nonsignificant reduction in fracture rate.
Furthermore, this study found a statistically significant risk
ofnephrolithiasis withsupplementation, with a hazardratio of
1.17 (95 % CI 1.02–1.34) . While this study showed a
nonsignificant reduction in overall fracture rate, there was a
42Curr Rev Musculoskelet Med (2013) 6:41–46
significant reduction in the healthy postmenopausal female
subpopulation when they received supplementation [37, 38].
As a result of the current evidence of an association between
hypovitaminosis D [25, 26••, 27••] and DRFs, stronger clin-
ical trials evaluating the efficacy of vitamin D assessment and
supplementation witheithervitaminD alone orvitaminD and
calcium are necessary.
Beyond minimizing physiologic risk factors for DRF, an
important factor to consider is fall prevention. The most
recent literature on fall prevention, the Lifestyle interven-
tions and Independence for Elders Study (LiFE study),
suggests functional-based exercise as a focus for the elderly
and high-risk fall patients. Self-reported fall incidences per
person-year were 1.66, 1.90, and 2.28 in the LiFE therapy,
structured exercise, and control groups, respectively; these
differences were statistically significant [39••]. While there
exist a multitude of specific exercise programs for fall
prevention available, concrete data on which specific exer-
cises are superior do not exist. However, these new data
suggest that an important factor in improving fall rates is to
integrate a strength and balance routine into daily activity,
rather than simply having a separate exercise program.
While preventative measures are important to patient
care, debate still exists on the acute management of DRFs
in the elderly. The treatment paradigm of DRFs for the
general population is restoration of anatomy, while the focus
in the elderly is restoration of function. Since the use of
internal fixation has become widespread, studies suggest
that in the general population, better functional outcomes
correlate with improved radiographic reduction [40–51].
The elderly population has traditionally been treated with
closed reduction and immobilization [52, 53, 54••]. Closed
reduction has been shown to fail and result in malunion in
over half of cases [54••, 55]. However, a majority of elderly
patients have adequate functional outcomes despite imper-
fect restoration of anatomy [32, 54••, 55–57]. The role of
internal fixation in DRFs of the elderly to restore function
remains controversial, since there are little data regarding
operative indications in the elderly. A retrospective study of
85,924 Medicare patients with a closed DRF explored what
factors correlated most strongly with internal fixation. This
study found that men were significantly less likely to receive
internal fixation than were women (OR- 0.84; 95 % CI
0.80–0.89) and black patients were significantly less likely
than were white patients (OR- 0.74; 95 % CI 0.65–0.85) [1,
58••, 59, 60]. Both patient age and the presence of comorbid
conditions exhibited a significant negative correlation with
the rate of internal fixation. Additionally, there was a great
deal of variability in the use of internal fixation based on the
treating surgeon. Patients treated by a hand surgeon were
significantly more likely to receive internal fixation than
were those patients treated by other orthopaedic surgeons.
Hand surgeons were more likely to perform internal fixation
over closed treatment, pinning/external fixation, or another
treatment with odds ratios of 2.40 (95 % CI 2.21–2.61), 3.22
(95 % CI 2.73–3.80), and 2.49 (95 % CI 2.29–2.70) respec-
in the use of internal fixation among hospital referral regions,
ranging from 4.6 % in Paterson, NJ to 42.1 % in Rome, GA.
with the percent of patients in each referral region who were
treated by a hand surgeon, r=.34, p<.0001 [58••].
DRFs, prevention of recurrence or injury with higher morbid-
ity is important. Evaluation of BMD following a DRF—
specifically,one resultingfromlow-energy trauma—iscrucial
to patient care and is insufficiently provided. Recent evidence
suggests that evaluation of osteoporosis and BMD examina-
tion should occur in the orthopaedic clinic setting following
DRF. Initiation of osteoporosis workup by the orthopedic
surgeon results in a statistically significant increase in osteo-
porosis treatment, as compared with referral to the patient’s
primary care physician for evaluation .
Evaluation for vitamin D deficiency in fragility fractures
and geriatric DRFs has slowly become a key component of
peri-injury workup. Prospective studies of vitamin D analysis
and supplementation following DRF have not been per-
formed, although the association between hypovitaminosis
D and DRFs, as well as other fracture patterns, suggests that
these studies would be beneficial [25, 26••, 27••]. DRFs have
been identified previously as a sentinel event for hip fracture,
making hip fracture prevention following DRF an important
element of DRF treatment [28–31]. A meta-analysis of the
pertinent literature suggests efficacy of vitamin D supplemen-
tation in hip fracture prevention [62••]. This study is the most
comprehensive and recent study on all of the vitamin D trials
on fracture reduction to date. It concludes that high-dose
vitamin D supplementation (>800 IU/day) may reduce hip
fracture risk in those older than 65 years, independently of
age orgender[62••].Treating DRFs asa sentinelevent for hip
vitamin D evaluation and supplementation following DRF.
DRFs disproportionately affect women of an advanced age.
Those at risk have been shown to have lower BMD, lower
vitamin D levels, and an increased risk of fall. The most
important treatment modality is prevention of fracture.
While standard guidelines for osteoporosis evaluation and
treatment have been well studied, the role of vitamin D
evaluation and supplementation is promising enough to
warrant further randomized study. Furthermore, fall preven-
tion is a promising component of risk reduction in the
elderly. We suggest that an exercise program that integrates
Curr Rev Musculoskelet Med (2013) 6:41–4643
strength and balance exercise into daily activities may be
superior to independent exercise regimens. Regarding acute
DRF management in the elderly, the primary goal is resto-
ration of function. Functional satisfaction in the elderly has
been achieved with imperfect anatomic restoration. The
ideal method of treatment, internal fixation versus closed
management, remains controversial in the elderly. The pre-
dominant factors determining use of internal fixation in
clinical practice are demographic and geographic, as well
as surgical preference. This warrants further study of quan-
titative surgical indications in DRFs of the elderly.
Following acute management, DRFs can be viewed as a
sentinel event for hip fracture. Hip fractures have a higher
of this injury pattern following a DRF is important. Recent
literature suggests that the burden of assessing BMD following
a DRF in the elderly lies with the orthopaedic surgeon, since
been unreliable. Furthermore, the role of vitamin D evaluation
and supplementation merits further review, since the most
recent studies suggest that this may reduce the risk of hip
fracture. Randomized control trials of appropriate serum vita-
min D screening protocols and vitamin D dosing following
DRF are necessary to fully determine the role this may play in
management. The literature on DRFs in the elderly remains
controversial. Patients will benefit from a deeper study of
preventative measures, standardized operative indications,
and a heightened clinical awareness of the role DRFs may play
as a sentinel event for hip fracture.
No potential conflicts of interest relevant to this article
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