Wrist Fractures in the Elderly: Is Surgery Necessary?

Wrist fractures are common in older adults. In particular, distal radial fractures receive a lot of attention. The radius is one of two bones in the forearm (located on the thumb side of the forearm).

With a fall or traumatic injury, fracture at the end of the bone at the wrist can be considered unstable if the broken pieces have shifted and no longer line up as they should. Is it okay to put a cast on an unstable distal radial wrist fracture and let it heal as is? Or is surgery really needed to reset the bone perfectly?

That’s the question orthopedic surgeons from the New York University Hospital for Joint Diseases asked. Their specific interest was in the older population. All patients included in the study were at least 65 years old. The average age was in the mid-70s. The goal was to compare results in patients with a distal radial fracture treated with cast immobilization to results for patients with the same diagnosis who were treated surgically.

You may wonder: doesn’t putting an unstable wrist fracture in a cast cause the bone to heal crooked or with some kind of misalignment? Yes, that is exactly what happened with one group. The other group had surgery to reset the break and hold it together with a metal plate and wires or an external device and pins. Anyone with an open fracture (bone poking through the skin) was automatically placed in the surgical group.

The results were measured (before and after treatment) in several different ways. X-rays were taken. A special test of function was given called the Disabilities of the Arm, Shoulder, and Hand (DASH). Grip strength and wrist motion were measured and recorded. Pain intensity was recorded at regular intervals (at two, six, 12, 24, and 52 weeks after treatment was started).

In the end, the differences between the two groups were negligible. In other words, the differences in motion, pain, function, and strength were so small, there was no difference. Complications (e.g., nerve compression, tenosynovitis, stiffness, wrist pain) were equal between the two groups. Carpal tunnel syndrome was more of a problem in the group treated without surgery but the symptoms went away and were not permanent. Scores for the DASH test were basically the same for patients in both groups each time they were tested.

The two differences seen during follow-up didn’t amount to anything significant. These included better grip strength in the group that had surgery when measured at the end of the first year. But this apparent weakness didn’t seem to affect function. The X-rays showed a cleaner, more stable fracture site for the operative group. The break in the bones was set so that the surgical group had a more normal angle and length of bone. But again, the less optimal radiographic findings in the nonoperative group only translated into a small decrease in wrist motion that didn’t affect function.

The researchers were careful to match patients between the two groups by age, sex, hand dominance, fracture pattern, socioeconomic status, and general health. That way comparing the two groups was not affected by these outside factors giving a more accurate look at the results. They summarized their findings by saying the following about the operative versus nonoperative treatment of distal radial (wrist) fractures:

  • Surgeons must evaluate each patient individually taking all factors into consideration.
  • Restoring normal wrist and forearm anatomy in distal radial fractures is not always necessary to get good results.
  • Malunion isn’t linked with poor function a year later.
  • These statements apply to older adults who are likely less active, lower-demand patients.
  • Wrist deformity doesn’t mean the final results of conservative care will be less than for patients who have surgery.

    Surgeons, patients, and family members can work together to decide when an older family member with a distal radial (wrist) fracture is going to need surgery or not. Given the likelihood that older adults have additional health concerns (e.g., diabetes, heart disease, high blood pressure), having a nonoperative approach available with positive outcomes is good news indeed.