The pendulum swings again for distal radius fracture treatments

Contemporary lifestyles have brought a change in treatment modalities through fixation and may emphasize removable splints rather than casts.

Issue: November 2005

Innovations in Orthopedics [icon] Distal radius fractures are among the most common bone injuries, comprising of one of every six fractures seen in emergency rooms. Treatment has long been conservative, especially for elderly patients. However, the past two decades have seen a switch to more operative interventions for all patients. Orthopedics Today spoke with some of the leaders of contemporary hand surgery to discuss which innovations they feel have most affected the treatment of distal radius fractures during their careers.

Jesse Jupiter, MD, chief, Upper Extremity and Trauma Service, Massachusetts General Hospital, Boston, said one great step forward in these treatments turns out to be patient motivated. “The first and foremost innovation has been a recognition that age, chronology, does not correlate with function. Across the board in our society, people are living longer and are much more active.”

Patient-driven outcomes have changed the perspective of approach-management of distal radius fractures dramatically. “Patients are now more interested in having a functional wrist and one that looks better and doesn’t hurt than ever before,” he said.

Public health issue

The changing demographics of our society have, in part, made distal radius fractures a public health issue. “They are considered under the fragility fractures with osteoporotic bone,” Jupiter said. “As people get older they fracture their wrists, hips and vertebrae more often. Numerically, that is a lot of injuries.”

Although distal radius fractures do occur in younger people, mainly from motor vehicle accidents or sport-related injuries, elderly patients make up a large percentage of these injuries. As our society ages, more people will be at risk. “If you look at it numerically, over the past 20-30 years, there are more of these fractures and the people that these are occurring in are more healthy and active. So the perceptions of both the patient and the physician have changed.”

Classification systems

Patients increasingly want distal radius fracture treatments that deliver a more functional wrist with less pain and better aesthetics.

X-ray of the wrist of a 76-year-old female patient, showing a common problem — a fractured radius caused by a fall. The fracture is located on the right side of the base of the head of the radius, just below the wrist. Osteoporosis often weakens the bones of older people, and contributes to distal radius fractures when they extend their hand to break a fall.

William P. Cooney III, MD, vice chair of the department of orthopedic surgery at the Mayo Clinic, Rochester, Minn., said he feels the development of treatment-based classification systems to be an important milestone in distal radius fracture treatment. Such systems usually dictate treatment, and suggest or correlate with anticipated long-term functional results. Cooney helped develop the Universal Classification System, one of the more popular methods for distal radius fracture assessment.

Cooney said that he too has seen the pendulum swing toward more operative interventions. “Up until just recently, you would treat the younger patients with the more aggressive surgery, however, there has been an unsubstantiated, but growing use of plate fixation in the elderly.”

Jupiter also said that this greater recognition of the types of injuries was an important innovation. “Historically, people gave them the same name — Colles fractures — and it is quite evident that they are not all the same.” The recognition that many of these fracture patterns are not amenable to traditional treatment has brought about a major shift in North America. “There has been a greater interest in interventional treatment rather than emergency room treatment and a cast, which was the standard treatment when I started.”

Surgical options

Cooney, a past president of the American Society for Surgery of the Hand, said that the development, along with the use of external fixation and the innovation of some unique surgical options — including the volar plate — have also advanced the treatment of these fractures. Key among these developments: treatments allowing for internal fixation of osteoporotic bone.

“The unique concept developed by Matthew Putnam of the University of Minnesota, of putting tines and screws just behind the distal surface of the radius in osteoporotic bone, helped to prevent the collapse that was so commonly seen with osteoporosis,” Cooney said. “In the past, the admonishment was, ‘don’t operate on those patients.’ Just in the last two years with his development of that technique and others taking it further, there are at least four or five types of volar tine or tine-plus-screw plate fixations which are being used in the elderly.”

Jupiter, who developed some of the fixed-angle implants that helped revolutionize internal fixation for distal radius fractures, said that newer implants allow patients to remain functional — an important quality of life issue. “Several years ago a nurse did a study looking at a large cohort of patients with distal radius fractures and looked at a variety of parameters, age, education, etc. It was clear that an older person in a cast has a lot more difficulties in coping and being independent than one would believe. So more of these people are being treated with surgery because it allows them to not need a cast and to be more independent.”

Outcomes assessment

The increased expectations of patients in regard to their postoperative outcomes are also shaping the management of distal radius fractures. Jupiter said that patient-rated tools, giving the patient’s perception of what their outcomes should be, is driving physicians to be more active in the management.

“If you take people who are older and maybe retired and anticipate playing golf or tennis, then they have a wrist fracture and they can’t turn their wrist well, it effects the way they thought their life would be like in retirement. If you talk to people who are now in practice in places where there are a large population of retirees, they realize that their treatment has to be more interventional because patients’ expectations are much higher.”

As in other orthopedic specialties, upper extremity surgeons look forward to using new biologics and biomaterials. Jupiter said many pharmaceutical companies tend to evaluate newer technologies in the distal radius because fractures there typically have a fixed time of healing.

But since distal radius fractures tend to heal well, biologics that increase the speed of healing may not be the future. Instead, materials like biologic bone cement may cause the treatment pendulum of these fractures to swing back toward casting.

“It is quite possible that things like biologic cements would have a terrific place here,” Jupiter said. “For example, the patient is in the emergency room with a distal radius fracture. It is manipulated so that it is straight and then you inject a cement-type of biologic. It could cement the fracture so you don’t need a cast and it would keep the reduction.”

Cooney said if the future holds a more cost-effective way to produce the TBF-ß growth factors, and they are found effective treatment modalities, then biologics might have a role in of distal radius fracture treatment. “We may find that a closed reduction cast and a good bone stimulating growth factor will speed the healing process and perhaps the use of the plates and external fixators will go the way casting was. The pendulum will swing back.

“You someday will be able to put a couple of k-wires in along with the bone morphogenic protein and hold the fracture enough until it heals. Then just pull your pins out and the fracture is healed and your patient is moving. I think biology is moving very quickly in that regard.”