If you are over 65 years old and you break your wrist in Great Falls, Montana, will you get the same treatment as if you are over 65 and the injury occurs in California or Florida or Colorado? Researchers from Dartmouth Medical Center noticed that there aren’t a lot of studies on the optimal treatment for distal radial fractures. So, they used Medicare records to answer a few questions about the current state of affairs.
First, how often does this type of injury occur? A distal radial fracture refers to the end of the radius (one of two bones in the forearm) at the wrist. Most often these fractures occur as a result of a fall on an outstretched arm. According to Medicare records, 125 out of every 10,000 people on Medicare have an injury of this type.
Older adults with balance problems and osteoporosis (brittle bones) seem to be the group with the largest rate of fractures in general. Wrist fractures of the distal radius occur in white women most often. In fact, women are almost five times more likely than men to break their wrists. White women are twice as likely as non-whites to fracture their wrists. Most of this was due to the higher rates of osteoporosis in white women.
The next question is: once a fracture is identified, how is it treated? There are three basic types of fracture treatment including 1) putting a cast on the arm, 2) slipping a wire through the skin to hold the bones together, a procedure called percutaneous fixation, or 3) open surgery to repair the fracture with metal plates and/or screws. This last category of surgery is referred to as open reduction and internal fixation (ORIF).
And the third question is: does treatment vary depending on where you live, how old you are, your race, or sex? They answered all of these questions by analyzing a sample of Medicare Part-B claims across the United States.
Since treatment is billed by a procedural code, they could use these codes to tell who had what kind of treatment. Patients treated by their primary care physicians in an outpatient (clinic) setting and those who were treated in a hospital or emergency department were all included. Over 300 hospital referral regions were identified by zip code and used to map out regions in the U.S. Colored maps were presented in the article to help the reader see where the largest numbers of patients were located and then what kind of treatment was given by region.
It turns out that the rate of wrist fracture goes up with age. The oldest group (over age 80) had the highest rate of wrist fractures. Most patients (83 per cent) could be treated nonoperatively. The remainder had surgery. Older patients are less likely to have surgery. And the rate of surgery increased (doubled) during the time of this study (between 1998 and 2004).
But the most striking finding was that the kind of treatment you might receive for a wrist fracture varied greatly depending on where you lived. Nonoperative care was more common in places like Kentucky (compared to California). Open surgery varied from 0.4 per cent in Pennsylvania to 25 per cent in Great Falls, Montana. Some of the differences noted were likely due to whether patients lived in an area where there is a high density of orthopedic surgeons and the type of hospitals available (e.g., teaching hospitals versus rural hospitals).
The biggest factor on whether or not surgery was done was the presence of comorbidities (other health problems). The more compromised the patients health was, the less likely they would have surgery. Race did not seem to be a major factor in the choice of treatment. Concern about cosmetic appearance might have had an effect on the type of operation performed.
One other finding from this study that mimics previous studies on ankle injuries is the presence of a fracture belt. Fracture belt refers to a higher number of fractures in a geographical region, specifically the northeastern section of the United States. Several factors may be linked with this pattern of distribution.
For example, weather conditions in that area with more ice and snow than in other places could be an important regional difference. Limited exposure to sunlight resulting in higher levels of osteoporosis and lack of water with fluoride in it could contribute to the higher level of osteoporosis-linked fractures. And possibly more involvement in sports activities may affect the rate of falls.
The authors conclude that although they were able to conduct a comprehensive overview on the incidence and type of treatment for wrist fractures, they still couldn’t really say why there is such a difference in how it’s treated from one region to another. There could be a wide range of variables such as physician training, cultural beliefs, or even personal or even religious preferences.
More studies are needed to determine the most appropriate care for distal fractures in this age group. Using the Medicare database was a helpful place to start, but it does not include information about how the injury occurred, the functional status of patients, or even the type of fracture present.