SCIENTIFIC ARTICLE

Effect of Patient Age on the Radiographic Outcomes of

Distal Radius Fractures Subject to Nonoperative
Treatment
Eric C. Makhni, BS, Timothy J. Ewald, MA, Sean Kelly, MD, Charles S. Day, MD

Purpose Our study assessed the radiographic outcomes of nonsurgically treated distal radius fractures
of patients who were 18 to 44 years old (group 1), 45 to 64 years old (group 2), and 65 years old or
older (group 3).
Methods All distal radius fractures seen in our emergency department from April 2002 to September
2004 that had nonsurgical management (either casting alone or closed reduction with immobilization)
were considered for this study (n ⫽ 124; 50 casted, 74 closed reduced). Patients were further classified
by age. Change in fracture alignment was assessed at the time of fracture union (approximately 8
weeks) and included measurements of angulation, articular gap/step-off, and radial shortening.
Results When the fractures (n ⫽ 124) were evaluated at union, there was an overall secondary
displacement rate of 64% (n ⫽ 79), with 42% in the group whose fractures were immobilized in a cast
and 78% in the group whose fractures were treated by closed reduction and cast. There was an increase
in displacement rate that was associated with increasing patient age. Among fractures that were only
casted, there was no such age-matched increase in rates of secondary displacement. However, when
considering those fractures that were subject to closed reduction (n ⫽ 74), rates of secondary
displacement significantly increased with age (58% in group 1, 81% in group 2, and 89% in group 3;
p ⫽ .03).
Conclusions Our study found that secondary displacement of distal radius fractures increased with
increasing patient age, primarily among fractures subject to closed reduction. Older patients with these
fractures require closer management after initial reduction, therefore allowing for better monitoring of
expected subsequent fracture collapse. Further, given these high rates of secondary displacement after
nonoperative treatment (58% to 89%), it is also important to consider that surgical treatment of these
fractures may be necessary. (J Hand Surg 2008;33A:1301–1308. Copyright © 2008 by the American
Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Prognostic III.
Key words Age-related outcomes, distal radius fracture, radiographic outcomes.

HE INCIDENCE OF distal radius fractures increases in the female osteoporotic population, they are still

T with age,1–3 and because of improving life ex-

pectancy, these fractures will continue to be a
common injury seen in the emergency department.
prevalent in younger patient populations as well, both
male and female.4,5 Despite this prevalence, typical
distal radius fracture studies often include patient co-
Even though these fractures are more commonly seen horts composed of only 1 age group. For those that do

From the Department of Orthopedic Surgery and the Department of Emergency Medicine, Beth Israel Correspondingauthor:CharlesS.Day,MD,HarvardMedicalSchool,andDepartmentofOrthopedic
Deaconess Medical Center, Boston, MA; and Harvard Medical School, Boston, MA. Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215; e-mail:
Received for publication November 28, 2007; accepted in revised form April 29, 2008. cday1@bidmc.harvard.edu.

No benefits in any form have been received or will be received related directly or indirectly to the 0363-5023/08/33A08-0006$34.00/0
doi:10.1016/j.jhsa.2008.04.031
subject of this article.

©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1301

1302 AGE AND NONOPERATIVE DISTAL RADIUS FRACTURES

include patients of a wide age variety, the results are

TABLE 1. Demographic and Treatment
rarely stratified by age. Thus, without these compara- Characteristics Of Enrolled Patients
tive results, it becomes difficult to extract practical
conclusions regarding the association of age and loss of Percent Percent Closed
Average Women Cast Only Reduction
fracture alignment after reduction and cast treatment.
Age Group Age (y) (%) (%) (%)
In the emergency room, closed distal radius
fractures are commonly treated by splinting (if Group 1 31 49* 46 54
nondisplaced) or by closed reduction (if dis- (n ⫽ 35)
placed).6 One recent randomized control trial has Group 2 54 82* 40 60
reported high rates of secondary displacement of (n ⫽ 45)
fractures after successful closed reduction.7 It is Group 3 77 86* 36 64
(n ⫽ 44)
therefore important to understand what factors
may be contributing to these outcomes. One major All patients 57 74 40 60
(n ⫽ 124)
question is whether or not age plays a role in the
gradual redisplacement of these fractures after re- The fraction of patients presenting with and without initial displace-
duction. If age does indeed affect the radiographic ment (those casted and closed reduced, respectively) were similar
across all 3 age groups (p ⫽ .71). However, the proportion of women
outcomes of these fractures, it may also affect the increased with increasing patient age (with * denoting statistical
radiographic outcomes of minimally displaced significance; p ⬍ .001).
fractures that do not require closed reduction and
only warrant casting immobilization. The goal of
this study is to examine the radiographic outcomes
of distal radius fractures subject to nonoperative under the age of 18 years, had combined radial/
management to determine the association of pa- ulnar shaft fractures, had operative fixation, or did
tient age and secondary fracture displacement. The not follow up their treatment at our institution. All
primary end point was “secondary displacement,” patients were managed by either orthopedic sur-
which included either loss of reduction (according geons (trauma or hand surgeons) or hand surgeons.
to previously defined radiographic criteria) that This study received institutional review board ap-
was noted in the fracture at union, or loss of proval at our institution, and strict patient confi-
reduction that necessitated operative fixation. For dentiality measures were followed.
minimally/nondisplaced fractures casted without The fractures in our study were treated with a cast
reduction, “secondary displacement” referred to (therefore no fracture manipulation) or closed reduction
fractures that established union with radiographic and cast immobilization. This decision was made by the
displacement or had radiographic displacement treating clinician and was based on the radiographic
that necessitated operative fixation. We hypothe- presentation of the fracture. All fractures were placed
size that nonsurgical management of these frac- in a sugar-tong splint by either the surgical (plas-
tures will lead to high rates of secondary displace- tics, orthopedics) resident or the orthopedic phy-
ment across all age groups (thus confirming sician’s assistant. Patients were also assigned to 1
previously published reports) and that these rates of 3 age groups. Those who were between 18 and
will increase with increasing patient age. Further, 44 years old were categorized as group 1; those
we postulate that the rates of secondary displace- who were 45 to 64 were considered group 2; those
ment within any given age group will be similar who were 65 or older were group 3.
for both fractures needing casting alone and for According to the aforementioned inclusion and ex-
those fractures requiring closed reduction. clusion criteria, 124 patients were included in this
study. The average age was 56 years, and there were 92
MATERIALS AND METHODS women. There were 50 fractures that received cast
Patients alone and 74 fractures that were subject to closed re-
This retrospective review includes all consecutive, non- duction and casting. Within this group of 124 nonsur-
surgically managed distal radius fractures seen in our gically managed patients, 35 were ages 18 to 44, 45
emergency department from April 2002 to September were ages 45 to 64, and 44 were ages 65 and older
2004. Patients were identified by ICD-9 codes in- (Table 1). The proportion of women within a given age
dicating fractures at the distal end of the radius. group increased with increasing patient age (p ⬍ .001).
Patients were excluded from the study if they were Further, the proportion of patients receiving casting

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 AGE AND NONOPERATIVE DISTAL RADIUS FRACTURES
TABLE 2. Radiographic Criteria for Secondary
Displacement/Loss of Reduction
Criteria Acceptable Value
Dorsal tilt7,8 ⬍10°
Volar tilt5,8
⬍25°
Radial shortening7,9,10 ⬍5.0 mm
Articular gap/step-off 9,10
⬍2.0 mm
Fractures that deviate from any 1 or more of the above criteria are
considered to be “displaced.”
versus closed reduction was similar across all age
groups (p ⫽ .71).
Data collection/analysis
Radiographic data were collected at 3 points in the
treatment course: at presentation, immediately after
splinting, and at a minimum of 8 weeks after immobi-
lization, when the fracture pattern and fracture frag-
ments would have reached a stable position. Whereas
clinical healing may not have been complete at this
time, “radiographic union” would likely have been es-
tablished,8 –10 such that any loss of fracture alignment
would have already occurred by this time point. For
fractures subject to closed reduction, postreduction ra-
diographs were obtained and assessed to confirm proper
anatomic alignment. All radiographs were analyzed
with respect to angulation, articular gap and step-off,
and radial shortening. Measurements were indepen-
dently made by 2 of the co-investigators (T.J.E. and
E.C.M.); any discrepancies that arose were referred to
the principal investigator (C.S.D.), who was blinded to
the name of the patient (as well as to any other quali-
fiers, such as age, treatment modality, or gender). All
measurements were made using digital radiographic
images (Centricity Enterprise Web v2.1, GE Health-
care, Chalfont St. Giles, UK) via the standardized an-
gular and linear measurement tools included in the
software. Radiographs of the noninjured side were not
available for comparison.
A literature review5,7,11–14 was conducted to con-
struct a set of radiographic parameters (Table 2) that
defined integrity of reduction. Specifically, those frac-
tures that displayed less than 10° of dorsal angulation or
25° of volar angulation were considered to have main-
tained reduction. Further, those with less than 2.0 mm
of articular gap/step-off or less than 5.0 mm of radial
shortening were also considered to have maintained
adequate reduction. These criteria, however, are not
universally accepted; instead, they were chosen based
JHS 䉬 Vol A, October 
1303
on the clinical practice and literature interpretation by
the authors. Moreover, these same criteria were used to
confirm the success of fracture reduction, with measure-
ments taken before and immediately after reduction.
Fractures were considered to have secondarily dis-
placed if they had a loss of reduction that necessitated
operative fixation or if they displayed loss of reduction
at union as defined in Table 2. The rates of secondary
displacement were then analyzed according to both
patient age and treatment modality (casting alone ver-
sus closed reduction).
In addition to comparisons of displacement rates
according to age and treatment, additional assessments
were made in order to determine the contribution of
other possible factors. For instance, comminution se-
verity and presence or absence of initial radiographic
displacement were investigated for possible influence
on secondary fracture displacement. The effects of pa-
tient gender on these secondary displacement rates were
also assessed.
Statistical analysis
When comparing simple proportions between indepen-
dent groups, the Fisher exact test (2-tailed) or a Pearson
chi-square test was used (for comparisons between 2
and 3 groups, respectively). Analysis of variance and
the Student’s t-test were used to determine mean dif-
ferences between groups when considering continuous
data. For all statistical sets, a 2-tailed value of p ⱕ .05
(*) was considered statistically significant.
RESULTS
Initial radiographs of all fractures were assessed with
respect to the parameters from Table 2 (angulation,
articular incongruity, and radial shortening). These
measurements were taken from radiographs of the frac-
tures on initial presentation (Table 3). The fractures that
had only cast immobilization displayed significantly
less angulation, articular gap, and radial shortening than
did those fractures that required closed reduction. The
success of the closed reduction (Table 4) in these dis-
placed fractures was judged according to the same
radiographic criteria. Both dorsal and volar angulation,
along with articular gap and radial shortening, showed
statistically significant improvement immediately after
closed reduction. Articular step-off, however, did not
significantly change after reduction, although it did
improve (1.7 mm and 1.1 mm before and after reduc-
tion, respectively; p ⫽ .12).
Of all 124 nonoperative distal radius fractures,
79 showed secondary displacement (evident in ra-
diographs outside the parameters of Table 2 or
1304 AGE AND NONOPERATIVE DISTAL RADIUS FRACTURES

TABLE 3. Initial Radiographic Comparison of Fractures That Were Subject to Casting Alone Versus
Those That Required Closed Reduction
Casting Only Closed Reduction

Parameter n Average ⫾ SD n Average ⫾ SD p

Dorsal angulation 16 10° ⫾ 5 61 26° ⫾ 11 ⬍.001

Volar angulation 29 9° ⫾ 6 8 28° ⫾ 11 ⬍.001
Step-off 9 1.5 mm ⫾ 1.5 28 1.7 mm ⫾ 1.7 .75
Gap 26 1.2 mm ⫾ 0.9 43 2.2 mm ⫾ 1.7 ⬍.01
Radial shortening 28 1.8 mm ⫾ 1.0 58 3.8 mm ⫾ 2.4 ⬍.001

Fractures that were subject to reduction displayed significantly higher angulation, articular gap, and radial shortening than did those fractures that
did not require closed reduction.

TABLE 4. Prereduction and Postreduction Characteristics of Fractures That Were Subject to Reduction (n
ⴝ 74) After Initial Presentation
Parameter n Prereduction Average ⫾ SD Postreduction Average ⫾ SD p

Dorsal angulation 61 26° ⫾ 11 3° ⫾ 14 ⬍.001

Volar angulation 8 28° ⫾ 11 10° ⫾ 13 .01
Step-off 28 1.7 mm ⫾ 1.7 1.1 mm ⫾ 1.1 .12
Gap 43 2.2 mm ⫾ 1.7 1.3 mm ⫾ 1.4 .01
Radial shortening 58 3.8 mm ⫾ 2.4 1.8 mm ⫾ 1.7 ⬍.001

Adequate reduction was achieved according to all 5 of the predetermined radiographic parameters.

FIGURE 1: Rates of secondary displacement among all nonsurgically managed distal radius fractures. For patients in groups 1
(18 – 44 years), 2 (45– 64 years), and 3 (65⫹ years), these rates increased significantly (*) with corresponding patient age (46%,
71%, and 70% for age groups 1, 2, and 3, respectively; p ⫽ .03).

subsequent need for surgical intervention). When
stratified by age (Fig. 1), this displacement was
noted in 46% of group 1 patients (n ⫽ 16), 71% of
group 2 patients (n ⫽ 32), and 70% of group 3
patients (n ⫽ 31). These results were statistically
significant (p ⫽ .03). Subsequent comparisons
were made among those fractures that were just
casted as well as those fractures that were subject
to closed reduction prior to immobilization.
Among those that were just casted (n ⫽ 50), a total
of 21 (42%) fractures showed evidence of second-
ary displacement at union (5 patients from group 1,

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 AGE AND NONOPERATIVE DISTAL RADIUS FRACTURES 1305

100%
*
90% *
80%
70%
*
60%
50%
40%
30%
20%
10%
0%
Cast Reduction Cast Reduction Cast Reduction
(n=16) (n=19) (n=18) (n=27) (n=16) (n=28)

Group 1 ((18–44) Group 2 (45–64)

( Gr
Group 3 (65+)
65+)

FIGURE 2: Rates of secondary displacement among fractures that were subject to cast alone versus closed reduction. The rate of
secondary displacement increased significantly (*) with increasing patient age (p ⫽ .03) among those fractures that received closed
reduction.

additional risk of secondary displacement. Of all

TABLE 5. Comparative Rates of Secondary
Displacement in Displaced Fractures Subject to
Closed Reduction Among Groups 1 (18 – 44 Years),
2 (45– 64 Years), and 3 (65ⴙ Years)
Reduced Fractures Displacement Rates (%)
Group 1 vs group 2 58 vs 81
Group 1 vs group 3 58 vs 89
Group 2 vs group 3 81 vs 89
Higher rates of displacement were found in group 2 and group 3
compared with that of patients from group 1.
10 in group 2, and 6 group 3; p ⫽ .32). Among the
74 fractures that were subject to closed reduction,
58 fractures (78%) showed evidence of secondary
displacement (Fig. 2) at this same time point.
These comprised 11 group 1, 22 group 2, and 25
group 3 patients (58%, 81%, and 89% displace-
ment rates, respectively; p ⫽ .03). When compar-
ing group 2 and group 3 patients to their young
counterparts, there was a trend toward increased
displacement among the group 2 patients (p ⫽ .10)
and a significant increase among the group 3 pa-
tients (p ⫽ .02; Table 5). Finally, we found that
fractures with initial dorsal angulation had similar
rates of secondary displacement as those with ini-
tial volar angulation (79% and 75%, respectively).
Given that a correlation was found between age
and radiographic outcomes in this set of distal
radius fractures, it was important to investigate the
contribution of any other variables that may affect
the outcomes in these patients. We first investi-
gated whether fracture comminution conferred any
124 fractures, 103 were determined to have no
more than 3 fracture fragments; the remaining 21
had 4 or more fragments. The rate of secondary
displacement of fractures with 3 or less fragments
p was 60%, and it was 81% in those with 4 or more
fragments. Although there was an increase in sec-
.10
ondary displacement among the more heavily com-
.02
minuted fractures, it was not statistically signifi-
.47
cant (p ⫽ .08).
In addition to comminution, the radiographic status
of the fracture on presentation was assessed for any
possible contribution to fracture outcome. We at-
tempted to determine whether initial radiographic dis-
placement was also correlated with age, thus correlating
it with radiographic outcome. Each fracture— on pre-
sentation—was assessed according to the parameters of
Table 2, and those that met the criteria for displacement
(ie, dorsal angulation greater than 10°, volar angulation
greater than 25°, etc) were considered to have been
initially radiographically displaced. Twenty-one of 35
group 1 fractures, 30 of 45 group 2 fractures, and 31 of
44 group 3 fractures demonstrated radiographic dis-
placement on presentation; there was no correlation
with age (p ⫽ .62).
Our final statistical consideration was that of gender
and its effects on the radiographic outcomes of the
distal radius fractures in our study cohort. Among group
1 patients, the rate of secondary displacement was 59%
for women versus 33% for men (p ⫽ .18). These results
were similar for group 2 (73% for women versus 63%
for men; p ⫽ .67) and for group 3 (74% for women
versus 50% for men; p ⫽ .34). Therefore, female gen-
der was not shown to correlate with increased likeli-
hood of secondary displacement, regardless of age.

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1306 AGE AND NONOPERATIVE DISTAL RADIUS FRACTURES

of secondary displacement at fracture union. Our over-

TABLE 6. Reasons for Secondary Displacement
According to Age and Treatment all rate of secondary displacement after closed reduc-
tion was 78%, which is comparable with that of Earn-
Reasons for Secondary Displacement (Cast Only/Reduced/ shaw et al.7 (73%). In that randomized controlled trial
Total)
conducted by Earnshaw et al., radiographic measure-
Group 1 Group 2 Group 3 ments were also used to determine occurrence of sec-
Outcome (18–44 y) (45–64 y) (65⫹ y) p ondary displacement after successful closed reduction
using such parameters as angulation and radial shorten-
Operation 0/8/8 4/9/13 1/14/15 .55
ing. Although the fractures in that study involved a
Dorsal angulation 4/2/6 6/10/16 4/9/13 .68
wide range of patient age (15–92 years), there were
Volar angulation 0/0/0 0/2/2 1/1/2 .65 unfortunately no conclusions made regarding patient
Gap 0/0/0 0/2/2 0/1/1 .57 age. Our study also includes a similar age range in our
Step-off 1/0/1 0/3/3 0/1/1 .56 patient cohort (19 –93 years); however, we have addi-
Radial shortening 0/1/1 0/2/2 1/7/8 .10 tionally made statistical comparisons of the outcomes
Total 16 38 40 according to different age groups.
Several recent studies have examined radiographic
Residual dorsal angulation, as well as successful secondary operation,
were the most common outcome of “secondary displacement” among outcomes of nonsurgically managed distal radius frac-
fractures in all 3 age groups. The proportion of fractures with these tures in elderly patient populations. Two of these stud-
outcomes, in addition to the other possible outcomes of volar angu-
lation, gap/step-off, or radial shortening, were not statistically differ- ies focused on patients with displaced fractures.
ent between the 3 different age groups. Beumer and McQueen15 found that closed reduction of
displaced fractures resulted in malunion in 53 of 60
(88%) patients who were either very elderly and low-
Because our criteria for secondary displacement con- demand or who had dementia. Loss of reduction was
sisted of 5 radiographic parameters, along with the judged according to angulation, radial shortening, and
end-outcome of operative fixation, we believed it nec- carpal alignment. The average age of these patients was
essary to include data pertaining to the exact reasons for 82 years (range, 65–93 years), and their rate of second-
secondary displacement among the treatment and age ary displacement was similar to that of the patients from
groups (Table 6). From these results, it appeared that our study (89% in patients 65 and older). In another
the 2 most common reasons for secondary displacement study by Young and Rayan,16 however, the radio-
were residual dorsal angulation (outside the parameters graphic outcomes were reported by the authors to be
of Table 2) and resulting successful secondary opera- more successful. This study included 25 sedentary and
tion. There was, however, no statistically significant low-demand patients over the age of 60 who sustained
difference in the ratio of patients with these outcomes displaced distal radius fractures with subsequent non-
among the 3 different age groups (p ⫽ .55 when con- operative treatment. According to their radiographic
sidering successful secondary operation; p ⫽ .68 when assessment, 68% of these fractures achieved either “ex-
considering residual dorsal angulation). In fact, none of cellent” or “good” results (24% and 44%, respectively).
the 6 variables (5 radiographic ⫹ successful operation) This assessment was made according to the modified
showed any statistically significant correlation with age. Lidstrom system used by Sarmiento et al.,17 which
employed dorsal angulation, radial shortening, and ra-
DISCUSSION dial inclination. However, relative to our assessment
Our study focused on patients with distal radius frac- parameters, the modified Lidstrom criteria allows for
tures managed by nonsurgical treatment methods (ei- more radiographic displacement in different categories.
ther cast alone or closed reduction and cast), and we For example, a “good” outcome in this system could be
sought to identify the effects of age on the rates of in a fracture that displayed 14° of dorsal angulation
secondary displacement of these fractures. We used a along with 6 mm of radial shortening; this fracture
set of radiographic criteria that defined “acceptable” would have been considered to be secondarily displaced
fracture dimensions. Using this approach, we found no in our study.
clear increase in secondary displacement rates with Two other studies examined patients with fractures
increasing age among fractures that received only cast that were both displaced and nondisplaced on initial
(without manipulation). However, in fractures that re- examination (similar to that done in our study). Jaremko
quired closed reduction prior to immobilization, we et al.8 followed up 74 such patients for 6 months after
found that increasing patient age led to increasing rates initial immobilization. These patients were all 50 years

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 AGE AND NONOPERATIVE DISTAL RADIUS FRACTURES
of age or older, and radiographs were assessed with
respect to a battery of parameters, including palmar tilt,
radial angle, radial height, ulnar height, and articular
gap/step-off. Seventy-one percent of all fractures did
not meet all of the acceptable radiographic parameters
when healed. In our study, among a similar age group
having nonoperative treatment (45 years and older), we
also found a secondary displacement rate of 71%. How-
ever, the study by Jaremko et al. did not stratify the
results of those fractures by initial displacement and
treatment modality. Further, no quantitative comments
were made regarding the success of the original reduc-
tion in that study. Our study reported on fractures that
were subject to both casting alone and those fractures
that were subject to closed reduction, and we quantita-
tively assessed those fractures that were reduced.
The second study examining both displaced and non-
displaced fractures was done by Anzarut et al.,18 and
they reported relatively good success after nonoperative
fracture management in 74 patients over the age of 50
years. Radiographically, only angulation (dorsal/volar)
was used to determine acceptable reduction at union.
Using this standard, only 36% of fractures (n ⫽ 27)
healed with unacceptable angulation. Whereas this ra-
diographic failure rate is lower than that found in our
study (81% and 89% for group 2 and 3 patients, respec-
tively), it is based on a much more limited set of
acceptable radiographic parameters (ie, they did not
take into account articular step-off and gap as well as
radial shortening). Similar to Jaremko et al., this study
also analyzed fractures managed with and without ini-
tial reduction with no reporting of subsequent stratifi-
cation of results based on initial displacement or treat-
ment modality.
Although age over 60 years has been considered to
be a risk factor for secondary displacement after reduc-
tion,19 we found high rates of such displacement in
patients in the group 45 to 64 years old (81%). Given
that successful reduction was confirmed prior to immo-
bilization in this study, it is reasonable to assert that any
secondary displacement was a gradual occurrence. It is
important to note that despite high rates of secondary
displacement among elderly patients (especially after
closed reduction), it is unclear what the actual func-
tional disabilities are from these outcomes. The set of
radiographic criteria that was used to assess fractures at
union was not specifically tailored to the elderly popu-
lation. Moreover, the study by Jaremko et al.8 attempted
to determine a correlation between radiographic out-
comes and patient satisfaction (using a combination of
subjective surveys such as the Disabilities of the Arm,
Shoulder, and Hand questionnaire and the Short-Form-
JHS 䉬 Vol A, October 
1307
12), but no such correlation was found. In another study
by Jupiter et al.,20 the radiographic and functional out-
comes of 20 patients aged 60 years or older who had
had operative fixation after unsuccessful initial closed
reduction were measured. The Patient-Rated Wrist
Evaluation, among other subjective measures, was used
to determine functional outcomes of these patients. The
investigators reported that the Patient-Rated Wrist Eval-
uation scores had no statistically significant correlation
with the radiographic outcomes of these fractures.
In contrast, other studies have indicated that there
may in fact be a correlation between functional and
radiographic outcomes of distal radius fractures. One
study by Trumble et al.21 assessed 49 patients with
52 displaced intra-articular fractures that were sub-
ject to operative fixation (open reduction internal
fixation). Range of motion and grip strength were
used to indicate functional outcome. The authors
reported that postoperative gap, step-off, total incon-
gruity, and radial shortening all were correlated with
the final functional outcome. In another study by
Knirk and Jupiter,14 intra-articular distal radius frac-
tures in 40 young adults (43 fractures) were assessed
to determine the contribution of radiocarpal incon-
gruity to the development of posttraumatic arthritis.
The authors found that, among all fractures with
articular displacement of 2 mm or greater, radio-
graphic signs of arthritis were evident after healing.
The findings from this study in part contributed to the
formation of the radiographic parameters used in this
study (Table 2).
As evident by the results of the aforementioned stud-
ies, the relationship between radiographic and func-
tional outcomes remains controversial.5,7,8 –10,14,21 If
there is indeed no correlation between radiographic and
functional outcomes in the elderly patient, then radio-
graphic assessment after reduction may no longer be
necessary. Closed reduction for displaced fractures may
serve some alternative purpose in these patients,
whether it is pain reduction, patient comfort, or preven-
tion of secondary comorbidities (ie, traumatic carpal
tunnel syndrome). Long-term radiographic outcomes
may prove to be irrelevant in this scenario. However, if
there actually is a correlation between functional and
radiographic outcomes, it may be necessary to closely
follow those distal radius fractures in patients over the
age of 45 years (ie, follow-up films at 1-week intervals
after reduction). If closely followed, fractures that ap-
pear to be “losing alignment” can be reassessed for
alternative treatment options (ie, open reduction and
internal fixation20) before a pronounced displacement
has occurred.
1308 AGE AND NONOPERATIVE DISTAL RADIUS FRACTURES
This study has inherent limitations. As a single-
center study, the results may not be universal to all
patient populations. Moreover, this was a retrospective
review and therefore may lack the strength of a pro-
spective trial. As mentioned, this study also only used
radiographic analysis to determine the success of the
outcomes. Despite the general acceptance of the radio-
graphic criteria used, there is still controversy over how
well the functional and radiographic outcomes correlate
with each other. Finally, given the importance of using
bone mineral density to assess overall bone health,
especially in the elderly patient population, it would
have been useful to incorporate these data into our
investigation.
Closed reduction management of distal radius frac-
tures is ineffective at obtaining satisfactory long-term
radiographic reduction, especially in older patients. For
example, in the age group 45 to 64 years, there was a
radiographic failure rate of approximately 55% in the
cast-alone group and 80% in the closed reduction and
cast group (Fig. 2) and a 70% secondary displacement
among all nonsurgically managed distal radius fractures
(Fig. 1) in groups 2 and 3. Many would consider this an
unacceptable failure rate, and surgical treatment of
these fractures may be indicated. We found no similar
increase in likelihood of secondary displacement
among older patients who presented with distal radius
fractures that were subject to casting/immobilization
alone. In this group, however, there was a 42% inci-
dence of loss of reduction. Additional age-related stud-
ies must be conducted not only to confirm these find-
ings but also to determine the precise relationship
between these radiographic outcomes and any associ-
ated functional deficiencies that may exist in these pa-
tients. This may involve the generation of new, age-
specific radiographic criteria that define acceptable
outcomes of distal radius fractures.
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