What is the management plan for a 71-year-old with a wrist injury?

Management Plan for a 71-Year-Old with a Wrist Injury

The management of a wrist injury in a 71-year-old patient should begin with a 3-view radiographic examination of the wrist, followed by appropriate immobilization and consideration for osteoporosis evaluation, as this represents a potential fragility fracture requiring a multidisciplinary approach. 1

Initial Diagnostic Evaluation

• A standard 3-view radiographic examination of the wrist (posteroanterior, lateral, and 45° semipronated oblique view) is the appropriate first imaging study for suspected wrist trauma 1
• Consider adding a fourth projection (semisupinated oblique) to increase diagnostic yield for distal radius fractures 1
• If initial radiographs are negative or equivocal but clinical suspicion remains high, consider:
  • CT without IV contrast to evaluate for occult fractures, especially for complex articular injuries 1
  • MRI without IV contrast if there is concern for concomitant ligamentous injuries, which may affect surgical treatment decisions 1

Acute Management

• Immobilization appropriate to the specific injury pattern identified:
  • For non-displaced fractures: splinting or casting 1
  • For displaced fractures: consider reduction and surgical fixation if:
    • Articular step-off is >2mm
    • Coronally oriented fracture line is present
    • Die-punch depression is present
    • More than three articular fragments are present 1
• Pain management with appropriate analgesics 2
• Early referral to hand specialist for definitive treatment if:
  • Suspected scaphoid fracture (most commonly fractured carpal bone)
  • Ligamentous disruption
  • Displaced fractures requiring surgical intervention 3

Special Considerations for Elderly Patients

• In patients over 70 years, wrist fractures often represent fragility fractures requiring additional evaluation 1
• An orthogeriatric and multidisciplinary approach is warranted, especially in frail elderly patients 1
• Evaluate for osteoporosis, as this injury may represent the first presentation of underlying bone fragility 1
• Consider starting anti-osteoporotic treatment even without a DXA scan in elderly patients with typical fragility fracture patterns 1

Rehabilitation Phase

• Begin rehabilitation once acute pain and swelling subside 2
• Focus on:
  • Restoring range of motion
  • Rebuilding strength
  • Regaining function for daily activities 2
• Tailor rehabilitation to the patient's specific needs, considering age, comorbidities, and functional requirements 1
• Monitor for complications such as:
  • Complex regional pain syndrome
  • Tendon rupture
  • Malunion 4

Secondary Fracture Prevention

• Implement systematic fracture risk assessment 1
• Consider pharmacologic therapy for osteoporosis:
  • First-line options: alendronate or risedronate (oral bisphosphonates) 1
  • For patients with oral intolerance, dementia, malabsorption, or non-compliance: zoledronic acid (intravenous) or denosumab (subcutaneous) 1
  • For very severe osteoporosis: consider anabolic agents such as teriparatide 1
• Ensure systematic follow-up to improve adherence to therapy 1
• Include non-pharmacological interventions and patient education 1

Follow-Up Considerations

• Regular monitoring for fracture healing and functional recovery 5
• Assessment of pain control and need for adjustment in analgesic regimen 4
• Evaluation of progress in rehabilitation and need for additional interventions 6
• Screening for complications of immobilization, particularly in elderly patients 1