Review Article

Distal Radius Fractures in

the Elderly

Abstract
L. Scott Levin, MD, FACS Distal radius fractures are common in elderly patients, and the
Joshua C. Rozell, MD incidence continues to increase as the population ages. The goal of
treatment is to provide a painless extremity with good function. In
Nicholas Pulos, MD
surgical decision making, special attention should be given to the
patient’s bone quality and functional activity level. Most of these
fractures can be treated nonsurgically, and careful closed reduction
should aim for maintenance of anatomic alignment with a focus on
protecting fragile soft tissues. Locked plating is typically used for
fracture management when surgical fixation is appropriate. Surgical
treatment improves alignment, but improvement in radiographic
parameters may not lead to better clinical outcomes. Treatment
principles, strategies, and clinical outcomes vary for these injuries,
with elderly patients warranting special consideration.

From the Department of Orthopaedic
Surgery, University of Pennsylvania
Perelman School of Medicine,
Philadelphia, PA.
Dr. Levin or an immediate family
member has received royalties from
Mavrek; has received research or
institutional support from AxoGen;
and serves as a board member,
owner, officer, or committee member
of the American College of
Surgeons, the American Society for
Reconstructive Microsurgery, the
American Society for Surgery of the
Hand, the International Hand and
Composite Tissue Allotransplantation
Society, the United Network for
Organ Sharing, the Vascularized
Composite Allograft Transplantation
Committee, and the World Society
for Reconstructive Microsurgery.
Neither of the following authors nor
any immediate family member has
received anything of value from or
has stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Rozell and
Dr. Pulos.
J Am Acad Orthop Surg 2017;25:
179-187
DOI: 10.5435/JAAOS-D-15-00676
Copyright 2017 by the American
Academy of Orthopaedic Surgeons.
March 2017, Vol 25, No
3 restore function.
he distal radius is the second
T most commonly fractured
bone
in elderly persons and the most
fre- quent upper extremity fracture
in women aged .50 years. Most
stud- ies define the elderly as
patients aged 50 to 75 years,1-10 a
range that is used in this review.
An increasingly active and
expanding elderly pop- ulation is
responsible for the increased
incidence of distal radius fractures
over the past 40 years.11
Controversy remains as to whether
these fractures should be treated
sur- gically or nonsurgically. Aside
from radiographic parameters of
displace- ment and angulation, the
decision to proceed to surgery
depends on the patient’s functional
outcome and activity level.
Particularly in elderly patients, the
potential for cosmetic deformity of
the wrist after non- surgical
treatment may influence the
personal decision to undergo cor-
rective surgery.12 Regardless of the
treatment modality, the goals of
care are to improve pain and
An evidence-based review of the
evaluation and treatment of distal
radius fractures, the effects on
health- care costs, and preventive
strategies reveals an intensified
focus on main- taining and
improving bone health in the
growing elderly population.
Epidemiology
Distal radius fractures account for
up to 18% of all fractures in the
elderly population.11 White race,
female sex, and osteoporosis are
risk factors for distal radius
fractures. There may also be
seasonal variations; elderly
patients are predisposed to
fracture in the winter months
because of slippery walking
conditions. Typi- cally, the
mechanism of injury is a fall onto
an outstretched hand. Patients
with intact cognitive and
neuromuscular systems may have
a higher risk of fracture because of
their reflexive ability to reach out
during a fall as opposed to falling
onto their side.13

179
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

In 2007, distal radius fractures
cost Medicare $170 million, or
$1,983 per beneficiary.14 Although
most distal radius fractures in elderly
patients are managed nonsurgically,
the use of internal fixation has
increased in the United States.
Internal fixation not only costs
Medicare nearly three times as much
as nonsurgical treatment,15 but it
may also increase hospitaliza- tion
rates and related expenses.
Despite the overall trend toward
internal fixation for distal radius
fractures, the practice varies demo-
graphically and geographically. In
a study of Medicare beneficiaries,
frac- tures were more likely to be
treated surgically in women and in
Caucasian patients.15 Furthermore,
the use of internal fixation ranged
from 4.6% to 42.1% among
hospital referral regions, a nearly
10-fold difference. Patients treated
by fellowship-trained hand
surgeons were also more likely to
undergo surgery.15
Clinical Evaluation
The clinical history should include
the mechanism of injury and pre-
senting reports, such as pain, loss
of function, and deformity.
Information regarding hand
dominance, hobbies, and
occupation is equally valuable. It is
important to ask about sequelae
from previous trauma to the upper
extremity or existing osteoarthritis
that may limit the patient’s
preinjury range of motion and
function. Inquiry into the use of
walking aids and independence in
performing activities of daily living is
crucial for a better understanding of
the demands on the elderly patient’s
upper extremities and may influence
treatment decisions.
A systematic examination of the
hand and wrist should progress
distally to proximally. The vascular
status of the hand should be
assessed by verify- ing digital
capillary refill and radial and ulnar
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is
L. Scott Levin, MD, FACS, et al
pulses at the wrist. The sensory
discrimination values and the ability to detect light
examination should include two-point
touch in the median, ulnar, and radial nerve
territories. The pres- ence of any paresthesia or
numbness in the median distribution warrants
careful attention because acute carpal tunnel
syndrome has been reported in 5.4% to 8.6% of all
distal radius fractures.16 The motor examination,
which may be limited secondary to pain, should
evaluate the anterior and posterior interosseous
nerves as well as the radial nerve proper and
median and ulnar nerves. The examiner should
also note the presence of lac- erations or skin tears
to rule out an open fracture, ecchymosis, edema, or
angular deformities (eg, dinner fork deformity).
Skin tearing is very com- mon in elderly patients
with thin soft tissues, and care must be taken,
espe- cially during closed reduction, to avoid
shearing of these tissues.
Radiographic Evaluation
Three radiographic views of the hand and wrist (ie,
AP, lateral, and oblique) are usually sufficient to
identify most distal radius fractures. Important
radiographic parameters to assess include, but are
not limited to, angula- tion, rotational deformity,
shortening, comminution, and joint alignment.
Specifically for distal radius fractures, parameters
include radial inclination (22°; mean, 19° to 29°),
radial height
(11 to 12 mm), and volar tilt (11°;
mean, 11° to 14.5°).17 Radiographs of the forearm
and elbow also should be obtained to detect more
proximal injuries or elbow instability. After closed
reduction and splinting, the clinician should obtain
radiographs documenting appropriate restoration of
the previously mentioned parame- ters. CT is
increasingly used by hand surgeons as a diagnostic
aid or to better quantify fracture patterns (ie, intra-
articular, impaction, shear frag- ments) and to aid
in surgical planning. CT may also be used when
revision
Distal Radius Fractures in the
Elderly
surgery, such as Kodama et al8 ulnar variance after closed reduc-
corrective osteotomy created a scoring tion.8 Although this scoring system
for malunion, is system to aid in may be used to guide treatment, it
considered. surgical decision has yet to be prospectively validated.
making for distal
radius fractures. For Nonsurgical
Management patients aged $50
years, important At our institution, minimally displaced
In the most recent fractures are initially placed in a
factors include
American Acad- emy sugar tong plaster splint (including
fracture pattern,
of Orthopaedic the elbow joint) to limit supination
radiographic
Surgeons (AAOS) and pronation (Figure 1). Fractures
parameters, age, hand
clinical practice with substantial displacement are
dominance, and
guideline on distal treated with closed reduction and
occupation. In a
radius fractures, the are immobilized in a sugar tong
multiple logistic
Work- group was splint. On the palmar aspect of the
regression analysis,
unable to hand, the splint ends just proximal
the authors found
recommend for or to the metacarpal heads, al- lowing
close correlations
against surgical early finger range of motion to
between clinical
treatment of these prevent stiffness and preserve
outcome and
fractures in elderly mobility. Limited compression with
comminution of the
patients.18 The rec- the elastic bandage wrapping holds
dorsal cortex and the
ommendation the splint in place. Fracture
volar cortex after
regarding volar characteristics deter- mine the
reduction, ulnar neck
locked plating versus
fracture, volar tilt preferred closed reduction
percutaneous pinning
before and after maneuver. Analgesia is provided by
was also graded
closed reduction, and the emergency department staff,
“inconclusive.”
and a

180 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is
hematoma block is infiltrated
directly into the fracture site, if Figure 1
possible.We place our patients in
finger-trap trac- tion before
reduction to fatigue the deforming
muscular forces surround- ing the
wrist. The index and long fingers are
placed in the traction device
coincident with the linear alignment
of the radiocarpal joint so as not to
exacerbate any deformity. In
general, the mechanism that is
causing the deformity is recreated,
and the mech- anism is reversed.
Multiplanar liga- mentotaxis
involves the combined use of
longitudinal traction and palmar
translation of the hand on the
forearm to allow the capitate to
rotate on the lunate, thereby tilting
the distal radial fragment in a A, Clinical photograph of the wrist demonstrating the use of a sugar tong
splint with slight volar mold and neutral rotation to prevent redisplacement of a
palmar direction.19 In the coronal
volar distal radius fracture. The splint should not extend beyond the
plane, radioulnar trans- lation metacarpal heads, and the fingers should show a normal cascade. AP (B) and
realigns the distal fragment onto the lateral (C) radiographs of the wrist show a well-padded sugar tong splint with
radial shaft.19 The typical Colles no wrinkles in the plaster or cotton roll.
fracture reduction involves placing a
thumb over the fracture site as a
lever, hyperextension of the fracture
frag- ment to disengage it from the
radial
metaphysis, longitudinal traction, and However, secondary in elderly patients and is reportedly
flexion to lever the dorsally displacement of distal radius as high as 89%.20 In osteoporotic patients
displaced fracture fragment into fractures upon conver- sion to treated nonsurgically, the cast serves more for
position. In elderly patients with a cast is still a risk; overall sec- fracture support and pain alleviation than
fragile skin and soft tissues, care is ondary displacement is more for anatomic reduction.7
taken to prevent skin tearing; this common Nondisplaced distal radius fractures in the
can often be avoided by placing a elderly may have a lower chance of
piece of cotton cast padding between subsequent displacement; however, at our
the patient’s skin and the institution, these patients are typically
physician’s fingers at the wrist scheduled for weekly follow- ups for 4 to 6
during the reduction. Finally, a weeks after injury to assess for secondary
careful neurovascular examination is collapse. At the follow-up visits, cosmetic
repeated after reduction. deformity of the wrist is discussed. Because
All patients are instructed to of the limited amount of soft tissue, the
follow up in 1 week for repeat patient should understand that his or her
radiographs. In patients who wrist may not appear as it did before injury.
undergo definitive non- surgical In a study of 13 women aged .71 years,
treatment, a short arm cast is McQueen and Caspers21 reported that 12
applied, and the patient is assessed had a mild to moderate cosmetic deformity
weekly for the first several weeks to at least 4 years after injury. Arora et al7
evaluate for secondary reported that, despite this clinical
displacement or collapse of the appearance, many elderly patients—
fracture. Conversion to a cast especially those with low demands— are
decreases the overall bulk of the able to live with their deformity.
splint and allows increased range of
motion and thus less stiffness.
Surgical
Surgical treatment options for
distal radius fractures in elderly
patients include closed reduction
and external fixation or
percutaneous Kirschner wire
fixation and open reduction and
internal fixation (ORIF) using a
volar or dorsal locking plate or a
dorsal bridge plate (Figure 2).
March 2017, Vol 25, No 3
Although fre- quently used,
the locked volar plate is not
without complications
(Figure 3). Another surgical
option for ORIF is dorsal
plating. The advantage of
dorsal plating for intra-
articular fractures is that it
allows visualization of the
joint surface without
disruption of the stouter
volar carpal ligaments and the risk of
future instability of the radio- carpal
joint. In volar lunate facet frac- tures,
fragment-specific fixation may be
used. An internal distraction plate
that uses ligamentotaxis to obtain
reduction is particularly beneficial in
patients with fractures that extend into
the radial diaphysis and in polytrauma
patients who may require load
bearing
181
Figure 2
quality of the bone,

AP (A) and lateral (B) radiographs of the wrist demonstrating external fixation of the distal radius in an elderly patient. C,
AP radiograph of the wrist demonstrating distal radius fixation with volar locked plating. D, AP radiograph of the wrist
demonstrating distal radius fixation with dorsal locked plating. E, AP radiograph of the wrist demonstrating distal radius
fixation with a spanning dorsal bridge plate. (Panel D copyright Derek J. Donegan, MD, Philadelphia, PA.)

through the wrist for mobilization. the size of the bone defect, blood flow to the
A distraction plate has also been fracture site, and the method of fixation and/or
effec- tive in the treatment of immobilization affect the healing process and the
comminuted, osteoporotic distal mainte- nance of the reduction.27 Given the added
radius fractures.22 This plate is morbidity associated with autogenous bone
removed after 12 weeks with good grafting, materials such as hydroxyapatite,
functional outcomes.23 tricalcium phosphate, and biphasic calcium
Volar locked plating has phosphate have been used. The use of allograft
improved radiographic outcomes in bone is advantageous because of its osteoconductive
terms of radial shortening, volar tilt, and osteoinductive properties, but it lacks the
and radial inclination, with a low osteogenic nature of autograft. In addition, allograft
complication rate reported.24 also lacks the same degree of structural properties
Clinically, it was also associated of autograft. Allograft bone does repre- sent a
with improved function, improved reasonable alternative if auto- graft is not available.
grip strength, and decreased pain in Citing the unique scaffolding properties of
the first 6 months compared with hydroxyapa- tite, a subcategory of allograft, Hegde
dorsal plating.24 Furthermore, et al28 used this graft in 27 patients aged .50
compared with volar locked years with distal radius fractures. They reported
plating, dorsal plating had a higher improved range of motion and maintained radial
risk of secondary fracture length (ie, no collapse) at 16-week follow-up.
displacement and extensor tendon Although no graft is ideal, Ozer and Chung27
irritation in up to 30% of cases.25 recommend the use of iliac crest bone graft in cases
Volar plating also showed superior of major bone loss and nonunion and
radiographic and clinical results
compared with percu- taneous wire
and external fixations in elderly
patients.2,26
To support the joint surface in
elderly patients with comminuted
fractures and metaphyseal bone
loss following restoration of length
and alignment, bone graft
substitutes are often used. The
 postoperative physical therapy
regimen for patients who sustain
calcium phosphate distal radius fractures is still
and allograft bone debated, and there is considerable
chips in other cases. variability between home-based and
Calcium phos- phate formal hand therapy programs.29
may work well in One systematic review examined
elderly patients the differences between formal
because of ease of therapy and home therapy and
use, rela- tively low found equal benefits among patients
cost, and the without sur- gical complications.30
potential to provide Souer et al31 found pain to be the
structural support most important independent
and thus satisfactory predictor of disability in patients
healing and who underwent volar locked plating.
functional recovery.27 In their cohort, formal physical
therapy did not improve average
Postoperative Rehabilitation disability scores or motion after 6
months, suggesting that patients
The optimal may benefit from more active

182 Journal of the American Academy of Orthopaedic Surgeons

Figure 3

AP (A) and lateral (B) radiographs of the wrist in a 74-year-old woman after open reduction and internal fixation of a
distal radius fracture. The initially well-fixed volar locking plate developed a complication in that the fracture collapsed,
resulting in penetration of the articular surface by screws. AP (C) and lateral (D) radiographs at the 4-week follow-up
visit.

and autonomous therapy versus a

passive approach that limits
progress according to pain
tolerance. How- ever, certain
patients may benefit from therapy
provided by a certified hand
therapist, including those with
decreased finger motion, advanced age,
and various comorbidities including
osteoarthritis, carpal tunnel syndrome,
and complex regional pain syndrome
(CRPS).29 Early finger range of
motion can help to prevent stiffness,
a major complication
immobilization fol- lowing distal
radius fractures.
Outcomes
Lutz et al32 compared the complica-
tions associated with nonsurgical
and surgical management of distal
radius fractures in elderly patients.
The authors found that, of 258
patients with an average age of 74
years who were identified in a
prospective data- base, the most
common surgical complication was
surgical site infec- tion (12%), and
the most common
nonsurgical complication was median nonsurgical versus surgical
treatment (regardless of fixation
neuropathy (11%). CRPS, extensor
strategy) of distal radius fractures
tendon rupture, and device
in elderly patients.5-7 Patients
irritation were also reported.32
treated surgically appear to have
Malunion is another complication
better grip strength than do those
associated with nonsurgical treatment,
treated nonsurgically, but they
with reported rates as high as 89%3
demonstrated no difference in the
and obvious deformity noted on
ability to perform activities of daily
physical examination. In a
living.7 In a recent randomized
systematic review of unstable distal
prospective trial comparing volar
radius frac- tures in elderly patients,
locked plating with closed
worse radio- graphic outcomes were
reduction and cast immobilization
reported in patients with fractures
of in patients aged .65 years, the
treated non- surgically; however,
surgical group showed better wrist
functional out- comes were similar
function in the early postoperative
between patients who were treated
surgically and those treated period.10 How- ever, at 6 and 12
nonsurgically.4 Major compli- cation months, there was no significant
rates were higher for fractures difference in wrist function or pain
between groups. At all time points,
treated surgically. Although patients
grip strength was considerably
often have minimal pain and
better in the surgical group.10
disability following nonsurgical
Overall, patient satisfaction with
treatment,3,32 the possibility of
surgical treatment remains high.
cosmetic deformity must be
In terms of cost, surgical treatment
discussed with them early to inform
is more expensive than nonsurgical
the treatment decision-making
treatment. Shauver et al33 performed
process (Figure 4).
an economic analysis of treatment
Multiple studies have shown no
of
difference in clinical outcomes of
March 2017, Vol 25, No 3 183
Figure 4

AP (A) and lateral (B) radiographs of the wrist demonstrating a distal radius fracture malunion in a low-demand 77-year-
old patient with an intra-articular distal radius fracture that was treated nonsurgically. AP (C) and lateral (D) radiographs
of the wrist obtained at 3-month follow-up show increasing consolidation. Clinically, the patient had 40° of wrist
extension, 15° of wrist flexion, and 60°/50° of pronation/supination, respectively, and was satisfied with the level of
function.

distal radius fractures in patients
aged $65 years. Although ORIF
was more expensive than casting,
surgery was found to be worthwhile
in terms of cost per quality–adjusted
life-year. After fracture of the distal
radius, pain, grip strength, and
range of motion may continue to
improve for up to 4 years after
injury.9 Despite the potential for
cosmetic deformity
associated with distal radius
fractures in the elderly and an
initial decline in independence that
necessitates assis- tance with
activities of daily living, patients are
able to adapt and regain much of
their functionality. In the setting of
distal radius malunion, long-term
functional outcomes are not affected,
even among highly active persons.
In a cross-sectional study of 96
patients aged $60 years, Nelson et
al34 found no significant difference
between those with a well-aligned
fracture and those with distal radius
malunion in terms of Disabilities of
the Arm, Shoulder, and Hand
(DASH) score, visual analog scale
function, strength, or wrist motion
at 1-year follow-up. A study of
“super- elderly” patients (defined as
those aged $80 years) with and
without malunion following
treatment of dis- tal radius fractures
found that the ability to perform
activities of daily living, wrist pain,
return to a normal level of function,
grip strength, and range of motion
were comparable.35 However,
Rozental et al36 found that the
survival rate after distal radius
fractures was only 57% at 7 years
compared with 71% for a matched
cohort without fracture at 7 years.
This effect was even more
pronounced in men; the reasons for
this finding have not been
elucidated but may relate to the
overall shorter lifespan of men
compared with women.36
Special Considerations for
Patients With Osteoporosis
In the elderly population, distal
radius fractures are considered to
be
related to osteoporosis. In a
Scandi- navian sample, the
prevalence of osteoporosis among
females who experienced a distal
radius fracture was 34% compared
with 10% in control subjects.37 In a
retrospective review of patients
who sustained distal radius
fractures, 64% were diagnosed as
having osteoporosis/ osteopenia
following screening.38 Patients
with a distal radius fracture also
had an increased rate of hip and
other osteoporotic fractures,39 an
incidence attributed to architectural
bone changes and more active life-
styles11 as well as balance
difficulties and heightened risk of
falls.
Because distal radius fractures typi-
cally occur many years before an
osteoporotic hip fracture,40 they may
serve as a tool to identify patients
with a heightened risk of more
debilitating fractures, allowing
appropriate lifestyle modifications
and medical treatment to decrease
this risk. Bone mineral density
(BMD) testing is commonly a
prerequisite to specialty referral,
and

184 Journal of the American Academy of Orthopaedic Surgeons

patients who sustain or have a
history of these fractures should be
referred for baseline osteoporosis
assessment, including possible
evaluation by an endocrinologist and
a bone densitom- etry scan. Given
the rising burden of osteoporotic
disease and its sequelae, a
comprehensive screening program
would benefit many patients.
Accord- ing to the International
Society for Clinical Densitometry
and the National Osteoporosis
Foundation, screening should
involve BMD testing for all women
aged $65 years and for men aged
$70 years.41
Compared with patients with
nor- mal BMD, those with
osteoporosis are at increased risk of
early instability, malunion, and late
carpal malalign- ment after distal
radius fracture.42 In a retrospective
study of 64 post- menopausal
women treated with ORIF for
distal radius fractures, the mean
DASH scores of those with
osteoporosis were 15 points higher
than the scores of patients with
os- teopenia. There was no
significant difference in range of
motion or radiographic data
between the two groups, yet the
osteoporotic group had a higher
rate of complications.42 An inverse
relationship has also been
established between BMD and
the severity of distal radius
fractures.42,43 Unlike fragility
fractures of the hip or lumbar spine,
distal radius fractures allow for
reduction and monitoring of the
alignment, making them more
amenable to objective comparisons.
Maintaining an anatomic reduction
is important for any patient, and
close follow-up within 1 to 2
weeks of closed reduction facilitates
determi- nation of definitive
treatment on the basis of fracture
displacement. In a retrospective
review of 78 patients aged .65
years with closed reduction of distal
radius fractures, no relation- ship
was found between BMD and the
ability to maintain reduction in a
splint.40 However, in another
study, despite reduction,
fracture displace- ment
returned to injury alignment
with respect to radial height and ulnar
variance in more than half of patients,
whereas volar tilt was maintained in more
patients.37
Treatment options for patients with
osteoporotic distal radius fractures include
diphosphonates and calcium and vitamin D
supplementation in addition to lifestyle
modifications. In a randomized trial of 50
women aged
.50 years, early initiation (ie, within 2 weeks
of injury) of diphosphonate therapy in those
with osteoporotic distal radius fractures
treated surgi- cally did not appear to affect
fracture healing or clinical outcomes, includ-
ing DASH score, wrist motion, and grip
strength.44 However, the use of volar locked
plating to achieve pri- mary bone healing in
these patients may have subverted the
potential deleterious effect of
diphosphonates on callus formation.
At our institution, elderly patients with
distal radius fractures are often referred for
further testing, especially if preliminary
laboratory test results, including calcium,
vitamin D, phos- phorus, and magnesium,
are normal. In patients for whom the
underlying cause of poor bone health is
incom- pletely understood, referral to meta-
bolic bone experts is suggested.
Vitamin C supplementation has also
received attention for its proposed effect on
preventing CRPS following distal radius
fractures, a complication observed in
approximately 10% of patients.45 Through its
action on oxygen free radicals, vitamin C is
thought to inhibit local proin- flammatory
cascades via antioxidant mechanisms.
Although the 2010 AAOS guidelines included
a moderate strength recommendation for the
use of vitamin C as an adjunct for pain
control,18 more recent studies and meta-
analyses have not corroborated the
correlation between supplemental use and the
incidence of CRPS.44,46
Debate exists regarding the role
that vitamin D plays in distal radius
fractures. Low vitamin D levels may
 be associated with distal radius
frac- tures in adults,
independent of BMD. In a case
control study of men and
women, an inverse dose-
response relationship between
vitamin D and distal radius
fractures was observed,
showing that low vitamin D
levels were a predictor of
fractures inde- pendent of
BMD.47 In a recent pro- spective
study of postmenopausal
patients with distal radius
fractures, up to 50% of those
with a fragility fracture did not
have osteoporosis as
demonstrated by BMD testing;
however, the authors found no
sig- nificant difference in vitamin
March 2017, Vol 25, No 3
should be undertaken in all elderly
patients, BMD testing should be
done, and necessary treatments
should be initiated to prevent
osteoporosis- related fractures. This
type of man- agement represents a
paradigm shift to preventive rather
than reactive medi- cine, and the
orthopaedic surgeon should play a
key role in this transition.
References
Evidence-based Medicine: Levels of
evidence are described in the table
of contents. In this article,
references 10, 43, and 44 are level I
studies. Refer- ences 15, 29, 33, 38,
39, and 42 are
level II studies. References 4, 31,
32,
34, 37, and 40 are level III studies.
Reference 22 is a level IV study.
References printed in bold type are
those published within the past 5
years.
1. Jupiter JB, Ring D, Weitzel PP: Surgical
treatment of redisplaced fractures of the
distal radius in patients older than 60
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2. Marcheix PS, Dotzis A, Benkö PE, Siegler
J, Arnaud JP, Charissoux JL: Extension
fractures of the distal radius in patients
older than 50: A prospective randomized
D levels between the
fracture group and the
control group.48 Higher
levels of bone turnover
markers, such as total
procollagen type 1 N-
terminal pro- peptide and
osteocalcin, were observed in
the fracture group,
suggesting that monitoring
bone turnover markers
may be more useful in
predicting fracture risk
than monitoring vitamin D
levels alone.48
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osteoporosis-related
fractures is increasing as
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3. Arora R, Gabl M, Gschwentner M,
Deml C, Krappinger D, Lutz M: A
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treatment versus volar locking plating. J
Orthop Trauma 2009;23 (4):237-242.
4. Diaz-Garcia RJ, Oda T, Shauver MJ,
Chung KC: A systematic review of
outcomes and complications of treating
unstable distal radius fractures in the
elderly. J Hand Surg Am
2011;36(5):824-835.e2.
5. Amorosa LF, Vitale MA, Brown S,
Kaufmann RA: A functional outcomes
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distal radius fractures. Hand (N Y) 2011;6
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