|Year : 2019 | Volume
| Issue : 1 | Page : 57-61
Long-term outcome of octogenarians with non-operatively treated distal radius fractures
Freek A van Brussel1, Eva A. K van Delft2, Charlotte J. L Molenaar3, Karlijn J van Stralen4, Niels W. L Schep5, Jefrey Vermeulen5
1 Department of Surgery, Ziekenhuis Amstelland, Amstelveen, The Netherlands
2 Department of Trauma Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam; Department of Surgery, Spaarne Gasthuis, Haarlem, The Netherlands
3 Department of Surgery, Spaarne Gasthuis, Haarlem, The Netherlands
4 Spaarne Gasthuis Academie, Spaarne Gasthuis, Hoofddorp, The Netherlands
5 Department of Surgery, Maasstad Ziekenhuis, Rotterdam, The Netherlands
|Date of Web Publication||19-Aug-2019|
Dr. Eva A. K van Delft
Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, De Boelelaan 1117, 1081 HV, Amsterdam
Source of Support: None, Conflict of Interest: None
Introduction: Distal radius fractures in patients over 80 years old are traditionally treated non-operatively. The aim of this study is to evaluate patient-reported outcome in octogenarians treated non-operatively for a distal radius fracture. Methods: Retrospective case study of all consecutive patients over 80 years old, treated non-operatively for a distal radius fracture after 1 year. The primary outcome was evaluated by the patient-rated wrist evaluation (PRWE) and quick disability of the arm, shoulder, and hand (qDASH) questionnaire, which were collected prospectively. Secondary outcomes were radiographic characteristics. Results: A total of 124 patients were included, male/female: 4/120, median age of 85 years. Fracture types were mainly Type A and C. The median follow-up was 1.3 years, 18 patients died and 6 patients were lost to follow-up for other reasons. The median PRWE score after follow-up was 3.25. Median qDASH score was 6.82. Only redisplacement after 1 week was associated with poorer outcome. Conclusion: The overall long-term patient-reported outcome of octogenarians with non-operatively treated distal radius fractures with or without deformity is excellent.
Keywords: Distal radius fracture, elderly, long-term functional, non-operative treatment, octogenarians
|How to cite this article:|
van Brussel FA, van Delft EA, Molenaar CJ, van Stralen KJ, Schep NW, Vermeulen J. Long-term outcome of octogenarians with non-operatively treated distal radius fractures. J Orthop Traumatol Rehabil 2019;11:57-61
|How to cite this URL:|
van Brussel FA, van Delft EA, Molenaar CJ, van Stralen KJ, Schep NW, Vermeulen J. Long-term outcome of octogenarians with non-operatively treated distal radius fractures. J Orthop Traumatol Rehabil [serial online] 2019 [cited 2020 Feb 21];11:57-61. Available from: http://www.jotr.in/text.asp?2019/11/1/57/264722
| Introduction|| |
In patients over 80 years old, so-called octogenarians, the incidence rate of distal radius fractures (DRF) in the Netherlands is 124 per 10.000 person-years in women. According to Dutch guidelines, octogenarians with a displaced DRF are treated with closed reduction and cast immobilization for 5–6 weeks.
However, some authors state that the results following open reduction and internal fixation (ORIF) are better, even in elderly patients. Others state that long-term functional outcome is satisfactory following non-operatively treated DRF in the elderly above 60 years of age. Little is known about patient-reported outcome in octogenarians following non-operatively treated DRF. Therefore, insight into this particular frail group of patients is necessary.
| Methods|| |
A retrospective cohort study, including all consecutive, non-operatively treated patients of 80 years and older with a DRF, was conducted. All patient charts on wrist fractures were hand searched. Patients above the age of 80 years, who presented at the emergency department of a teaching hospital in the Netherlands between January and December 2015 because of a DRF, were analyzed retrospectively. The patient-reported outcome was collected prospectively. Patients with isolated distal ulnar fractures or antebrachii fractures were excluded. During the inclusion period, only four patients were treated operatively and analyzing those patients was therefore abandoned. Patients were treated by closed reduction and cast immobilization for 5–6 weeks. Demographics such as sex, age, fracture on dominant hand, period of cast immobilization, and radiographic characteristics were measured. Moreover, all fractures were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen classification and were analyzed independently by two assessors (FB and JV).
The primary outcome was the patient-rated outcome measured by the patient-rated wrist evaluation (PRWE) and the quick disability of the arm, shoulder, and hand score (qDASH) after at least 1 year of follow-up. Secondary outcomes were radiographic characteristics, redisplacement after 1 week and malunion. Redisplacement and malunion were defined as volar angulation >20° or dorsal angulation >15°, radial inclination <5°, or ulnar variance >5 mm.
The PRWE-score ranges from 0 to 100, with zero indicating no pain and functional impairment. The minimal clinically important difference (MCID) for the PRWE is 11.5 points. With the qDASH patients can score pain and functional outcome on a numeric scale from one to five, one being the best possible outcome and five the worst. The total sum was counted and converted to a score ranging from 0 to 100, where zero is the best possible outcome and 100 the worst. The MCID of the qDASH is set at 14 points.
The distribution of the data was checked for normality by visually inspecting the histograms and boxplots. Normally distributed data were reported as mean and standard deviation and non normally distributed data were reported as median with interquartile range (IQR).
We analyzed covariates – age, dominant hand, and radiologic characteristics in univariate analysis. As PRWE and qDASH were not normally distributed, for measuring the P value, subgroups were log transformed. P values for differences between groups were determined using linear regression analysis. Categorical data were presented as the absolute frequency and the percentage.
Variables with P < 0.10 in univariate analysis were entered into the multivariable analysis. A multiple regression analysis was performed. Data were analyzed with IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk, NY, USA), released 2016.
| Results|| |
A total of 124 patients with DRF were assessed for eligibility. The median age was 85 years (IQR: 83–88), 120 of them were female (97%). 41 of all fractures (33%) were intra-articular. 60 patients (48%) had closed reduction before cast immobilization. 37 patients (30%) suffered redisplacement after 1 week, 60 patients (60%) showed malunion after cast immobilization. In this study, no reduction or correction osteotomy was performed in case of redisplacement or malunion. The patient characteristics are displayed in [Table 1]. There was no significant difference in baseline characteristics.
67 patients (54%) completed the questionnaires. 18 patients (15%) died within a year after trauma and 33 patients (27%) were not able to complete the questionnaires because of cognitive impairment, while 6 patients (5%) were lost to follow-up [Figure 1]. The 67 patients who completed the questionnaires, had a median PRWE-score of 3.5 (IQR: 0–21.5) and a median qDASH-score of 6.82 (IQR: 0–22.7) after a median follow-up of 1.3 years (IQR: 1.2–1.4).
[Figure 2] shows examples of the common practice of octogenarians with displaced DRF that were treated by reduction only and had an excellent PRWE (patient 1:1.00, patient 2:6.00) and qDASH (patient 1:0, patient 2:6.82) after 1 year.
|Figure 2: X-ray of representative cases. Patient 1: Example of an 82 year old female who was treated by reduction only. A: X-ray after trauma, B: X-ray after 5 weeks of cast immobilization. Patient 2: Example of an 81 year old female who was treated by reduction only. A: X-ray after trauma, B: X-ray after 5 weeks of cast immobilization|
Click here to view
In univariate analysis, significant difference was reached for dorsal angulation, ulnar variance, closed reduction, redisplacement after 1 week and malunion after cast immobilization (P < 0.05) [Table 2]. Both statistical significance as well as the MCID of 11.5 for the PRWE score was reached in patients with dorsal angulation >15° (22/67), and patients who suffered redisplacement after 1 week (21/67). The mean PRWE score in patients with dorsal angulation >15° was 17.5 versus 2.3 (difference: 15.2; P = 0.004). In patients who suffered redisplacement after 1 week, the mean PRWE score was 19.3, versus 1.8 in patients who did not suffer redisplacement (diff: 17.5, P = 0.002). None of the parameters listed in [Table 2] reached a significant difference for the qDASH.
|Table 2: Univariate regression analysis for median PRWE and qDASH-scores for patient characteristics and radiological characteristics|
Click here to view
Multivariate analysis was performed to determine possible significant predictors on PRWE score. Variables with P < 0.10 in univariate analysis were entered into the multivariate analysis. Dorsal angulation, ulnar variance, closed reduction, re-displacement after 1 week and malunion had a P < 0.10 in univariate analysis and were analyzed [Table 2]. Only redisplacement after 1 week was identified as a significant predictor for poorer outcome in multivariable analysis [P = 0.001, [Table 3].
|Table 3: Multivariate regression analysis of characteristics with statistical difference in univariate analysis|
Click here to view
| Discussion|| |
In this cohort study, the patient-reported outcome of octogenarians with non-operatively treated DRF was excellent, with a median PRWE of 3.5 and a median qDASH score of 6.82 after a median follow-up of 1.3 years. Only patients with dorsal angulation of >15° and patients who suffered redisplacement after 1 week had a significant as well as clinical important difference in patient-reported outcome measured by PRWE score. The multivariate analysis showed that only redisplacement after 1 week had a significant relation with worse PRWE scores after at least 1 year of follow-up. The question remains if these patients will benefit from primary surgery. The additional research on this factor in the future will help to optimize the treatment of octogenarians.
One can question, whether the reduction of displaced DRF in octogenarians should even be performed. As only redisplacement after 1 week, and not closed reduction or malunion, was associated with poorer patient-reported outcome after 1 year, this might be the case. However, as a well-performed reduction might prevent redisplacement after 1 week, reduction could improve the outcome. In this study, the performance of closed reduction did improve outcome significantly. Moreover, to draw clear conclusion among the urgency for the reduction in DRF in octogenarians, further research is necessary.
The effect of fracture characteristics on poorer functional outcome has been described in literature. In a study that included 642 patients with a mean age of 59 years, functional outcome was determined by range of movement, grip strength, and activities of daily living. Both dorsal comminution and malunion were associated with a decrease in grip strength and functional score. However, only univariate analysis was performed. Furthermore, patients in this study were younger than the population in our study.
In another study, 751 patients above 60 years of age were analyzed. 59 patients, with 60 DRF, were unfit to undergo surgery and were treated non-operatively. Malunion occurred in 53 of the 60 fractures. The authors state that if a good anatomical position could not be maintained, one can question if primary reduction should even be performed. Unfortunately, patient-reported outcome is not measured in this study.
A systematic review and meta-analysis on operative versus nonoperative treatment of DRF in elderly patients was performed. They state that operative treatment results in better radiographic outcomes and grip strength according to nonoperatively treated DRF, at the expense of the number of complications in the operatively treated group: tendon injury and major complications requiring surgery. Pain, functional assessment, and range of motion did not differ between the non-operatively and operatively treated DRF. In this systematic review and meta-analysis, there was no evidence supporting a better overall functional outcome in the operative treatment of DRF in elderly patients. However, in this review, patients above the age of 60 years were considered elderly.
In the past, it has been suggested that elderly patients with DRF tolerate displacement or malunion better than younger patients and therefore, anatomic reduction in elderly patients is not always necessary. Some authors state that patients, over 65 years old, can use their hand and wrist, even with deformity, without experiencing difficulties in daily life. In a retrospective study, patients over 70 years old were evaluated, comparing ORIF (n = 53) and nonoperatively treated DRF (n = 61). Follow-up after 1 year showed no difference in patient-reported and functional outcomes between the two groups. The PRWE-score was 9.3 in the ORIF group, versus 16.9 (P = 0.21) in the non-operatively treated group. Radiological results were significantly better in the ORIF group. The same research group prospectively compared unstable DRF treated with volar plate versus cast immobilization in patients over 65 years old. Grip strength was significantly better after 1 year in patients treated by ORIF. PRWE score showed no difference between the two groups (12.8 vs. 14.6, P = 0.73). A significant number of complications in operatively treated DRF in patients over 65 years old was found in a case–controlled study that compared operative and non-operative treatment in 158 patients. There was no significant difference in patient-reported outcome after 1 year. This study shows that redisplacement after 1 week was a significant predictor of poorer outcome; however, the question remains if these patients will benefit from primary surgery. Additional research on this factor in the future will help to optimize the treatment of octogenarians.
All of the studies mentioned above concluded that there is no advantage of surgical treatment over nonsurgical treatment in the elderly. However, in all these studies, patients over 60 years old were considered elderly. Nowadays, patients in their sixth decade still fully participate in working life, sports, and active recreation. In this study, octogenarians are considered to be the new elderly.
The mortality in this cohort was 15% however, the correlation between mortality and DRF itself is not clear. One-year mortality in this population is slightly higher than in the general population, which is about 10% but is much lower than that for patients with hip fractures, which is about 20%., The potentially increased risk of death could be real, and caused by immobilization and resulting in a diminished activity in daily life. However, it is more likely to be linked to confounding factors such as frailty that causes both an increased risk of fractures as well as a higher mortality. The overall excellent PRWE and qDASH scores suggest that the function itself does not influence daily life significantly.
Patient-reported functional outcome can be assessed accurately by use of subjective, validated scoring systems. The PRWE and the qDASH have proved valid, reliable, and responsive measures of outcome following DRF., PRWE score is the most responsive instrument for evaluating the patient-reported functional outcome in patients with disorders of the wrist. The MCID of the PRWE is 11.5 points although this is evaluated for younger patients, with a mean age of 59 years. The qDASH score is considered to be the best instrument for evaluating patients with disorders involving the joints of the upper limb, with an MCID of 14 points. These questionnaires were originally designed for younger patients. One can argue that the MCID of octogenarians is higher, considering the low-demanding function. Moreover, it seems to be the best available method to monitor subjective functional outcome in elderly patients, including octogenarians.
The retrospective design of this study is a limitation. However, primary outcome measures were collected prospectively, and 97% of all consecutive DRF of octogenarians were included in this study; therefore, the cohort is representative for common practice in general hospitals. In this cohort, only six patients were lost to follow-up. The patients with mental impairments (n = 33) did not report significant complaints of pain or functional impairment; however, they could not be evaluated properly by patient-reported outcome measures as the PRWE and qDASH-scores because of their mental impairment. Furthermore, the baseline characteristics were not significantly different; it could be possible that these mentally impaired patients had poorer PRWE and qDASH scores [Table 1]. Mentally impaired patients are suggested to have lower demands. The beginning of mental problems might even result in poorer outcomes itself, because of less frequent training or recovery treatment.
| Conclusion|| |
The patient-reported outcome of octogenarians with nonoperatively treated distal radius fractures after at least 1 year of follow-up is excellent. Only redisplacement after 1 week might be a predictor on poorer patient-reported outcome. The question remains, however, if these patients will benefit from primary surgery.
The first and second author made equal contributions to this article and therefore shared the first authorship.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bentohami A, Bosma J, Akkersdijk GJ, van Dijkman B, Goslings JC, Schep NW. Incidence and characteristics of distal radial fractures in an urban population in the netherlands. Eur J Trauma Emerg Surg 2014;40:357-61.
de Putter CE, Selles RW, Polinder S, Hartholt KA, Looman CW, Panneman MJ, et al.
Epidemiology and health-care utilisation of wrist fractures in older adults in the netherlands, 1997-2009. Injury 2013;44:421-6.
Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am 2011;93:2146-53.
Chen Y, Chen X, Li Z, Yan H, Zhou F, Gao W. Safety and efficacy of operative versus nonsurgical management of distal radius fractures in elderly patients: A systematic review and meta-analysis. J Hand Surg Am 2016;41:404-13.
American Academy of Orthopaedic Surgeons. The Treatment of Distal Radius Fractures, Guideline and Evidence Report. American Academy of Orthopaedic Surgeons; 5 December, 2009.
MacDermid JC, Turgeon T, Richards RS, Beadle M, Roth JH. Patient rating of wrist pain and disability: A reliable and valid measurement tool. J Orthop Trauma 1998;12:577-86.
Walenkamp MM, de Muinck Keizer RJ, Goslings JC, Vos LM, Rosenwasser MP, Schep NW. The minimum clinically important difference of the patient-rated wrist evaluation score for patients with distal radius fractures. Clin Orthop Relat Res 2015;473:3235-41.
Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH): Validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord 2006;7:44.
Sorensen AA, Howard D, Tan WH, Ketchersid J, Calfee RP. Minimal clinically important differences of 3 patient-rated outcomes instruments. J Hand Surg Am 2013;38:641-9.
Cowie J, Anakwe R, McQueen M. Factors associated with one-year outcome after distal radial fracture treatment. J Orthop Surg (Hong Kong) 2015;23:24-8.
Beumer A, McQueen MM. Fractures of the distal radius in low-demand elderly patients: Closed reduction of no value in 53 of 60 wrists. Acta Orthop Scand 2003;74:98-100.
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.
Grewal R, MacDermid JC. The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients. J Hand Surg Am 2007;32:962-70.
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.
Lutz K, Yeoh KM, MacDermid JC, Symonette C, Grewal R. Complications associated with operative versus nonsurgical treatment of distal radius fractures in patients aged 65 years and older. J Hand Surg Am 2014;39:1280-6.
Centraal Bureau voor de Statistiek, Aantal Overledenen; 2014.
Mears SC, Kates SL. A guide to improving the care of patients with fragility fractures, edition 2. Geriatr Orthop Surg Rehabil 2015;6:58-120.
Karnezis IA, Fragkiadakis EG. Association between objective clinical variables and patient-rated disability of the wrist. J Bone Joint Surg Br 2002;84:967-70.
Goldhahn J, Angst F, Simmen BR. What counts: Outcome assessment after distal radius fractures in aged patients. J Orthop Trauma 2008;22:S126-30.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]