This article was updated on May 13, 2014. The third bullet point, which had previously read “Patients who have or are at risk of sustaining a distal radial fracture generally are elderly, are female, and have lower bone mineral densities and lower serum vitamin-D levels” was redundant with the second bullet point. The third bullet point now reads as follows: “Patients with a distal radial fracture are at an increased risk for future falls, which can lead to further morbidity and mortality.”
➢ Distal radial fractures are increasingly contributing to the health and economic burden in the elderly.
➢ Patients with or at risk for distal radial fracture are generally elderly, female, and have lower bone mineral densities and lower serum vitamin-D levels.
➢ Patients with a distal radial fracture are at an increased risk for future falls, which can lead to further morbidity and mortality.
➢ Treatment of patients with distal radial fracture should include preventive measures to help reduce future fracture risk, including laboratory testing, bone densitometry, and proper initiation of medical therapies.
As a consequence of our aging population, the public health burden of osteoporosis has reached epidemic proportions1. In 2004, 10 million persons in the United States carried the diagnosis of osteoporosis, and the prevalence of osteopenia reached 34 million2. Every third postmenopausal woman and every fifth man older than fifty years is estimated to have osteoporosis3. The World Health Organization (WHO) defines osteoporosis as a bone mineral density more than 2.5 standard deviations below the young adult mean for a given population4. Patients with decreased bone mineral density have increased bone fragility and are at increased fracture risk, especially for distal radial fracture5.
The incidence of osteoporotic fractures was greater than 2 million in 20056. The economic burden of osteoporotic fractures amounts to $18 billion in direct medical costs annually7, and this number is expected to grow by 150% by the year 20256. Patients with distal radial fracture make up a major portion of the osteoporotic fracture population. In 2001, more than 640,000 distal radial fractures were reported in the United States, with the incidence on the rise worldwide8-12. As life expectancy and elderly activity continue to increase, distal radial fractures will disproportionately affect the population of patients who are sixty-five years of age or older, accounting for almost 20% of all fractures in this population13-15. The annual cost of treating distal radial fractures in the elderly has been estimated to range from $385 million to $535 million6,16. Additional costs include physician fees, facility fees, and the costs of structured rehabilitation programs and hand therapists. Nonmonetary costs are equally important, particularly since prolonged disability in the elderly can last eighteen months or longer after injury17. This review will summarize the risk factors for distal radial fracture and the concomitant goals of treatment for this population: primary prevention, acute management, and reduction of future fracture risk.
Pathophysiology and Risk Factors
It is well described that both age and sex play important roles in the development of distal radial fracture. In subjects older than sixty-five years, women are approximately five times more likely than men to sustain a distal forearm fracture14. Brogren et al. also noted that the incidence of distal radial fracture increased rapidly in women from the age of fifty years onward, almost doubling every ten years until age ninety18. The incidence in men remained comparatively low until age eighty, at which time it increased but still remained much lower than that seen in women18,19.
The architectural and qualitative changes and decreased bone mineral density of aging bone, in conjunction with the fact that the older population of the U.S. has become increasingly active, may help explain this epidemiological pattern20. In fact, numerous studies have found low bone mineral density in elderly women who have sustained a distal radial fracture, with reported rates of osteoporosis ranging from 33% to 60%21-26. Moreover, osteoporosis has also been shown to correlate with the severity of distal radial fracture, with lower bone mineral density associated with more severe, intra-articular fractures27,28. Clayton et al. also revealed that decreases in bone mineral density are associated with an increase in the probability of early instability, late carpal malalignment, and malunion28.
Vitamin D and parathyroid hormone regulate calcium metabolism and influence bone health. In vitamin-D deficiency, gastrointestinal calcium absorption is decreased and parathyroid hormone increases, which in turn stimulates calcium release from the skeleton and can lead to increased susceptibility to osteoporosis and fractures29. Vitamin-D deficiency has also been associated with muscle weakness and an increased risk of falling30. It is therefore not surprising to note that low serum vitamin-D levels have also been linked to distal radial fracture. Wright et al. showed that 49% (eighteen of thirty-seven) of male patients with distal forearm fracture had vitamin-D insufficiency or deficiency, as defined by a serum level of <50 nmol/L31. Similarly, Jang et al. found that 44% (forty-six of 104) of female patients with distal radial fracture had vitamin-D insufficiency or deficiency as compared with 13% (fourteen of 107) in an age-matched control group32. Finally, Oyen et al. found the correlation between low vitamin-D levels and distal radial fracture to be independent of bone mineral density, body mass index, or smoking history29.
Seasonal variations in the occurrence of distal radial fracture have also been reported. In Finland, 173 (60%) of 289 distal radial fractures were found to occur in the winter months. Upon further analyses, Flinkkilä et al. found that the number of fractures was 2.5 times greater on slippery winter days and 1.4 times greater on normal winter days when compared with the number of fractures that occurred on nonwinter days19. This has led to the likely hypothesis that there is an increased number of mechanical falls from a standing height or less as a result of inclement weather and slippery surfaces. Moreover, Jang et al.32 investigated seasonal variation in the occurrence of distal radial fracture as well as the serum level of vitamin D in postmenopausal women being treated for distal radial fracture and found that the level of vitamin D in that population was significantly lower in autumn and winter months as compared with those in a matched control group of patients without a fracture (21% and 29% lower, respectively; p = 0.049 and p = 0.001, respectively). This finding may be attributed to decreased daylight hours and less time with sun exposure, leading to less synthesis of vitamin D32. The combination of increased fall risk and decreased vitamin-D synthesis may help explain the observed seasonal variations20.
There are three main pillars with regard to the treatment of distal radial fracture in the osteoporotic patient: (1) primary prevention, (2) acute management, and (3) reduction in future fracture risk.
One of the best preventive measures is the efficient diagnosis and management of osteoporosis. The United States Preventive Services Task Force (USPSTF) recommends screening for osteoporosis in women who are sixty-five years or older and in those whose fracture risk is equal to or greater than that of a sixty-five-year-old white woman with no additional risk factors. The National Osteoporosis Foundation recommends screening in men who are seventy years or older2. Bone mineral density examination of the hip and spine by dual x-ray absorptiometry (DXA) is currently the standard for diagnosing osteopenia and osteoporosis. The T-score is the primary unit of measure, equal to the number of standard deviations above or below the mean for a healthy thirty-year-old adult of the same sex as the patient. Individuals with a T-score at or below −2.5 are classified as osteoporotic, and those with a T-score between −1 and −2.5 are classified as osteopenic4. However, bone mineral density revealed by DXA testing does not always accurately reflect fracture risk, as up to 50% of those who sustain hip or other nonvertebral fracture do not have osteoporosis according to the results of bone mineral density testing33-35. Nonetheless, bone mineral density examination is still invaluable for the purposes of diagnosis and treatment monitoring. Since the majority of fragility fractures occur in individuals who are diagnosed with osteopenia, there is an increased emphasis on bone quality in addition to bone density. Alternative imaging modalities to DXA, such as high-resolution peripheral quantitative computed tomography (HR-pQCT) and micro-magnetic resonance imaging (micro-MRI) are being investigated to better ascertain fracture risk. Several studies have shown the ability of HR-pQCT to detect differences in total density, trabecular number, trabecular density, and trabecular thickness even after adjusting for age and bone mineral density by DXA36-39. These architectural differences are not measured by DXA but have the potential to alter treatment algorithms by identifying skeletal fragility at earlier stages. Although these imaging modalities are not yet widespread, they have the potential to better stratify the millions of osteopenic patients who may benefit from targeted pharmacologic therapy in order to reduce fracture risk.
In addition to bone mineral density testing, the USPSTF has used the Fracture Risk Assessment tool (FRAX; World Health Organization Collaborating Centre for Metabolic Bone Diseases, Sheffield, United Kingdom) to estimate the ten-year risk of sustaining hip and other major osteoporosis-related fractures (spine, forearm, and shoulder)40. This algorithm uses clinical risk factors in addition to bone mineral density to estimate fracture risk. Risk factors examined include age, sex, weight, height, previous fracture, parent with a hip fracture, smoking status, glucocorticoid use, rheumatoid arthritis, secondary osteoporosis, and more than three alcoholic beverages per day. The FRAX tool has been adopted in several countries and has demonstrated the ability to stratify patients according to risk factors41,42. Based on the FRAX tool, pharmacologic treatment is ultimately recommended for postmenopausal women and men over the age of fifty years who have low bone density (T-score of ≤−1 at the femoral neck, total hip region, or spine) and a ten-year probability of sustaining a hip fracture of ≥3% or a ten-year probability of sustaining an osteoporosis-related major fracture of ≥20%43.
Pharmacologic options for osteoporosis treatment include bisphosphonates, selective estrogen receptor modulators, estrogen, calcitonin hormone, parathyroid hormone, and monoclonal antibodies. Although selective estrogen receptor modulators have been shown to reduce fracture risk, they also elevate the risk of sustaining a thromboembolic event. Estrogen has been associated with increases in thromboembolic events, coronary heart disease, and breast cancer rates44,45. Calcitonin and parathyroid hormone data are limited by the relatively small numbers of trials that have been conducted and by inconsistent reporting of adverse events46,47. Human monoclonal antibodies are emerging drug therapies that are currently under investigation. One such drug is denosumab, a human monoclonal antibody to the receptor activator of nuclear factor kappa-B ligand (RANKL) that inhibits osteoclast differentiation and activation. In early studies, it is has been shown to decrease bone resorption and increase bone mineral density at the hip and spine48-50. Bisphosphonates have been the most studied to date. They have the best effect and have the least serious adverse event profile, typically making them the treatment of choice47. Although numerous options exist, alendronate sodium (70 mg, taken once per week and available in a generic formulation) is considered first-line therapy51,52. For those who cannot follow dosing instructions reliably or are unable to tolerate oral bisphosphonates, a once yearly infusion of zoledronic acid is an effective alternative53. Data from a study of patients with hip fracture who were treated with zoledronic acid within ninety days of fracture showed a 35% risk reduction of subsequent fracture as well as a 28% all-cause mortality reduction54. Rare adverse events have been reported with bisphosphonate use (e.g., osteonecrosis of the jaw in 0.04% of patients, and atypical femoral fractures); however, the beneficial effects of this drug outweigh the absolute risk of experiencing an adverse event in most patients27.
The USPSTF currently recommends against vitamin-D and calcium supplementation in the general population, primarily based on the results of the Women’s Health Initiative (WHI)55,56. This study examined 36,282 healthy postmenopausal women from age fifty to seventy-nine years old who were randomly assigned to receive 1000 mg of calcium carbonate with 400 IU of vitamin D3 daily versus placebo. Fractures were ascertained for an average follow-up period of seven years. In the treatment arm, there was a small but significant increase in hip bone density (1.06% increase), no reduction in hip fracture rate, and an increased risk of nephrolithiasis (hazard ratio [HR] of 1.17; 95% confidence interval [CI], 1.02 to 1.34)55. In an updated recent report, the USPSTF determined that there are insufficient data to assess the balance of the benefits and harms of daily supplementation with >400 IU of vitamin D3 and >1000 mg of calcium for the primary prevention of fractures in postmenopausal women57.
Research focusing on the avoidance of fracture has also documented success in preventing falls and thus unnecessary health care expenditure58-60. For instance, Rizzo et al. randomized 301 subjects over the age of seventy years with risk factors for falling to either an intervention arm or a usual-care arm. The intervention arm received a combination of medication adjustment, behavioral recommendations, and exercises. The total mean health-care costs were approximately $2000 less in the intervention group as a result of decreased falls58. Additionally, the recent lifestyle interventions and independence for elders study randomized subjects who were seventy years of age or older who had two or more falls in the year prior to one of three home-based intervention groups: the lifestyle integrated functional exercise (LiFE) approach group (in which 107 participants were taught principles of balance and strength training and integrated selected activities into everyday routines), the structured program group (in which 105 participants were taught exercises for balance and lower-limb strength, to be performed three times a week), or the sham control program group (in which 105 participants were taught to perform gentle exercise). The overall incidence of falls in the LiFE group was 1.66 per person years, compared with 1.90 in the structured group and 2.28 in the control group, which represented a 31% significant reduction in the rate of falls60. Furthermore, even less elaborate interventions, such as increased warning signs for inclement weather and more effective snow and ice removal, may also lead to a decrease in the incidence of primary distal radial fracture19,27.
While there is a plethora of research on the treatment of distal radial fracture in the general population, guidelines are less clear in the elderly and osteoporotic population. Restoration of anatomy is the traditional paradigm for distal radial fracture in the general population, while restoration of function is generally accepted in the elderly population20. Numerous studies suggest that better functional outcomes correlate with improved radiographic reduction61-67. While the elderly population has traditionally been treated with closed reduction and/or casting, this has shown to result in malunion in more than half of cases68,69. The results of some studies have suggested that operative treatment has several advantages in this population, including improved grip strength and improved radiographic outcomes with regard to dorsal tilt, radial inclination, and radial length70-72. Despite these results, numerous studies have demonstrated that regardless of treatment choice, elderly patients still have adequate functional outcomes as measured by various indices, including range-of-motion score, pain score, Disabilities of the Arm, Shoulder and Hand (DASH) score, and the patient-rated wrist evaluation (PRWE) score68-74. Contributing to this controversy is the fact that there are very few prospective, randomized controlled trials on this subject. Of those few, most have compared operative to nonoperative treatment and, to our knowledge, none have evaluated outcomes exclusively in the elderly75. The recent appropriate use criteria for distal radial fractures, published by the American Academy of Orthopaedic Surgeons, further illustrates the controversy regarding the optimal treatment method for these patients76. When distal radial fracture cases were presented to a voting panel, several management options, including closed reduction followed by immobilization as well as open reduction and internal fixation with volar locked plating, were chosen as equally appropriate76. The panel concluded that, to establish definitive guidelines, there is a need for further Level-1 or Level-II data from studies in which internal fixation with use of the more recent volar locked plating construct is compared with other treatment methods in the elderly population. There is similarly no consensus on the indications for bone-grafting for distal radial fracture. The panel concluded that, until more data are available, clinicians may proceed with the appropriate treatment that they feel most comfortable using76.
Interestingly, despite the lack of clear operative indications in the elderly, internal fixation is being increasingly utilized77. The rates of internal fixation range from 4% to 50%, as variables (in addition to patient age) such as sex, patient comorbidities, surgeon subspecialty, and geographic variability all appear to contribute as well68,69,78,79. An analysis of 85,924 Medicare beneficiaries with closed distal radial fractures illustrated that fractures were significantly less likely to be treated with internal fixation in men than in women (odds ratio [OR] = 0.84; 95% CI, 0.80 to 0.89) and in black patients than in white patients (OR = 0.74; 95% CI, 0.65 to 0.85). Additionally, patients were more likely to be treated with internal fixation rather than with other treatments if they were treated by a hand surgeon rather than if they were treated by an orthopaedic surgeon without hand specialty training (OR = 2.49; 95% CI, 2.29 to 2.70)68.
Regardless of treatment methodology, maintenance of functional hand and wrist motion is crucial for preservation of independent activities of daily living, especially in the elderly and osteoporotic population. Karantana et al. and Goehre et al. recently demonstrated that volar locked-plate fixation versus percutaneous fixation resulted in no differences in long-term functional outcomes but did result in earlier recovery of function, which may be advantageous to patients and can help explain the increased use of internal fixation73,80. In addition to the initial injury, secondary functional deficiencies can occur due to swelling, nerve compression, and patient avoidance to use the hand. Early range-of-motion activities, particularly through the use of hand therapy, elevation of the affected extremity, and minimal use of prolonged sling or tight casting, can help minimize functional consequences81-83. Additionally, early mobilization of the forearm helps prevent elbow stiffness and loss of rotation, both of which have been shown to be vital for activities of daily living such as hygiene and eating15,20,81,83.
Reduction in Future Fracture Risk
Distal radial fracture can be associated with an important functional loss. In the Study for Osteoporotic Fractures, women with a wrist fracture were 50% more likely to experience functional decline, as defined by worsening ability to prepare meals, perform heavy housekeeping, climb ten stairs, go shopping, and get out of a car84. In addition to causing functional deficits, distal radial fracture has a direct impact on mortality rates. Data gathered from the National Death Index and the Centers for Disease Control and Prevention showed the mortality rate in 325 patients with a distal radial fracture to be significantly higher than that in the unaffected elderly population. Specifically, the cumulative estimated survival in the study cohort was 57% compared with an expected value of 71% for the U.S. population at seven years after distal radial fracture (p = 0.002)85.
In addition to the direct functional and mortality effect, patients with distal radial fracture are at an increased risk of sustaining a future fragility fracture. There is a 5.2 times greater vertebral fracture rate in women and 10.7 times greater vertebral fracture rate in men in the year following a distal radial fracture. Additionally, in this same time period, there is a 1.6 to 1.9 times increased rate of hip fracture in women who are older than seventy years86,87. In a meta-analysis, Haentjens et al. demonstrated a 3.26 increase in the relative risk of sustaining a hip fracture among men following distal radial fracture, which was a stronger association than that seen among postmenopausal women88. Among both genders, the disease burden of such complications is monumental. One-year mortality rates following hip fracture range from 12% to 37%89-92. Moreover, approximately one-half of patients never regain their ability to live independently93. Finally, the estimated cost of hip fracture treatment and sequelae is between $10.3 to $15.2 billion per year in the United States alone94-96.
Since distal radial fracture occurs at a younger age than hip or vertebral fractures do, a distal radial fracture in an elderly person can be one of the first indicators of underlying osteoporosis and a critical juncture for intervention. Today, only 3% to 20% of patients with a distal radial fracture are examined for possible osteoporosis, and only 8% to 30% are treated for osteoporosis by medication29. This rate remains unacceptably low despite recent efforts to increase identification and treatment rates for osteoporosis among this at-risk population97. Additionally, men are less likely than women to be evaluated and treated for osteoporosis98-100. Unpublished data from our group from a retrospective study specifically evaluating distal radial fractures showed that men were less likely than women to be evaluated and treated for osteoporosis despite being identified as being at high risk with use of the FRAX tool.
In order to improve the management of osteoporosis in patients with fragility fractures, the American Orthopaedic Association initiated the “Own the Bone” project in 2005. Using quality-improvement tools designed to improve the application of evidence-based strategies for the prevention of secondary fractures, the project produced significant improvements (p < 0.0001) in patient counseling on calcium and vitamin-D supplementation, exercise, fall prevention, and communication with primary care providers. However, no improvements were shown in the ordering of bone mineral density testing or in the initiation of osteoporosis pharmacotherapy101. Bone mineral density testing by DXA remains the standard for evaluation of fracture risk. Rozental et al. demonstrated that ordering a bone mineral density examination in the orthopaedic surgery clinic can dramatically improve osteoporosis evaluation and treatment rates following distal radial fracture. They randomized patients to one of two groups: Intervention 1, in which the orthopaedic surgeon ordered a bone mineral density examination and forwarded the results to the primary care physician, or Intervention 2, in which the orthopaedic surgeon sent a letter to the primary care physician outlining guidelines for osteoporosis screening. After six months, the patients who were randomized to Intervention 1 had two to threefold greater rates of bone mineral density testing (93% compared with 30%, p < 0.001), discussion of osteoporosis with their primary care physician (89% compared with 35%, p < 0.001), and initiation of osteoporosis therapy (74% compared with 26%; p < 0.001) as compared with the patients who were randomized to Intervention 297. It is acceptable to initiate osteoporosis treatment after an initial fragility fracture because prior fracture is a risk factor in itself for future fracture. However, bone mineral density examination is very useful for establishing a clinical baseline and monitoring the efficacy of osteoporosis treatment. The aforementioned study is an important illustration not only that patients are more likely to be treated for osteoporosis if a bone mineral density examination is obtained, but also that the orthopaedic surgeon should initiate this process because reliance on primary care physicians is less effective.
In general, patients with a fragility fracture should be evaluated for easily treatable factors that may be contributing to the decline in bone quality. A thorough history should be taken and should include information regarding prior fragility fractures and prior osteoporosis treatments, including treatment with bisphosphonates. A medical evaluation can be obtained in high-risk individuals to determine whether blood levels of calcium, 25-hydroxyvitamin D, thyroid-stimulating hormone, and parathyroid hormone are sufficient or require correction. A complete blood count and chemistry panels may also be helpful. When indicated, a more detailed workup includes the acquisition of twenty-four-hour urine calcium values, the performance of serum protein electrophoresis, and an evaluation for Cushing disease and testosterone deficiency2,102,103. Patients who have metabolic abnormalities such as hypercalcemia, hyperparathyroidism, and metabolic acidosis should be referred to an endocrinologist for further evaluation. Similarly, patients who have already received bisphosphonate treatment for longer than five years or have had more than two fragility fractures merit additional evaluation103.
Despite the lack of clear guidelines in the general population, it is recommended that patients with a fragility fracture have adequate intake of calcium and vitamin D, either through dietary or supplementary sources. According to current guidelines, individuals older than fifty years and those with fragility fractures should consume 1200 mg of calcium and 800 to 1000 IU of vitamin D daily2,103. This amount of vitamin D is typically sufficient, but dosing should be adjusted to achieve a goal serum level of 30 to 40 ng/mL of 25-hydroxyvitamin D104.
Due to the suppressive actions on bone remodeling, it was originally theorized that bisphosphonates would disrupt the fracture-healing process; however, in patients with an osteoporotic distal radial fracture treated with volar locking plate fixation, the early initiation of bisphosphonate treatment at two weeks after the operation versus three months after the operation did not affect fracture-healing or clinical outcomes105. In another study, in which radiographic healing of distal radial fractures in patients who were receiving bisphosphonate therapy at the time of injury was compared with that of patients who did not have bisphosphonate exposure, bisphosphonate use was associated with slightly longer times to radiographically evident bone union. The small differences in healing times (less than one week), however, were not considered clinically relevant106. It is well established that treatment with bisphosphonates or other antiresorptive drugs can result in as much as a 50% decrease in the risk of future fracture; thus, strong consideration should be given to initiating treatment in patients with distal radial fracture107-110.
Suggested Treatment Algorithm
We recommend that all patients with fragility fractures, including distal radial fracture, be evaluated for underlying abnormalities in bone mineral density. This includes laboratory testing when indicated and referral to an endocrinologist if any major abnormalities are detected. Calcium and vitamin-D supplementation should be initiated, if necessary, to reach the target daily goals of 1200 mg of calcium and 800 to 1000 IU of vitamin D. Bone densitometry testing and use of the FRAX tool should occur concurrently. Resultant osteopenic/osteoporotic T-scores of −1 or less, along with a ten-year hip fracture risk of ≥3% (or a ten-year overall fracture risk of ≥20% alone), should prompt initiation of bisphosphonate therapy or other antiresorptive treatment. Throughout this process, close communication with the patient’s primary care physician is paramount, but the orthopaedic surgeon should take the lead in ensuring appropriate screening and treatment for osteoporosis.
The lack of clear evidence to demonstrate the superiority of any one type of treatment allows for surgeons and patients to together determine the optimal treatment for the fracture itself. While individuals who are more active may benefit from operative treatment, others will accept a malunion in order to avoid surgery. While we prefer to use volar locked plating for elderly patients with osteoporotic bone, the choice of surgical treatment method is left to the treating surgeon. In this arena, as is true in many areas with limited evidence, shared decision-making is the mainstay of treatment.
Distal radial fractures are increasingly contributing to health and economic burdens, especially within the elderly population. Patients with or at risk of sustaining a distal radial fracture are generally elderly, female, and have lower bone mineral densities and lower serum vitamin-D levels than their counterparts. They are also at an increased risk of sustaining future fractures, which can lead to further morbidity and mortality. Treatment strategies consist of primary prevention to reduce the risk of distal radial fracture, acute management to mitigate any resulting functional deficit, and reduction of future fracture risk through the effective use of screening modalities and medical therapies.
Sources of Funding: No external funding source was used for this study.
Investigation performed at the Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
- Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated