Is a DonJoy (Dynamic Orthotics and New Joint) short arm brace sufficient for a comminuted distal radius fracture in an elderly patient?

DonJoy Short Arm Brace for Comminuted Distal Radius Fracture in Elderly Patients

A DonJoy short arm brace (removable splint) is generally insufficient for a comminuted distal radius fracture in an elderly patient and should not be used as definitive treatment. 1

Why Removable Splints Are Inadequate for Comminuted Fractures

Comminuted fractures require more rigid stabilization than what a removable brace provides. The AAOS/ASSH guidelines distinguish between stable, minimally displaced fractures (which can be managed with removable splints) and comminuted fractures, which represent a more severe injury pattern requiring different management. 1

• Comminuted distal radius fractures are inherently unstable due to multiple fracture fragments and typically fail to maintain acceptable alignment with simple immobilization alone. 2
• The fracture pattern in comminuted injuries is predicated upon higher energy mechanisms and often poorer bone quality in elderly patients, making them prone to displacement. 1

Treatment Algorithm for Elderly Patients with Comminuted Distal Radius Fractures

Step 1: Assess Fracture Characteristics

Check for the following parameters that indicate need for operative intervention:

• Radial shortening >3 mm 2
• Dorsal tilt >10 degrees 3, 2
• Intra-articular displacement or step-off >2 mm 2

Step 2: Initial Management Decision

For comminuted fractures meeting operative criteria:

• Surgical management (particularly open reduction and internal fixation with volar locking plates) is increasingly preferred, though conservative management remains prevalent in the elderly population (>65 years). 1
• If surgery is chosen: Volar locking plates are commonly used, though severely comminuted patterns may require spanning fixation or fragment-specific fixation techniques. 4

For comminuted fractures NOT meeting operative criteria (rare):

• Rigid cast immobilization is required—not a removable splint. 5
• Closed reduction followed by casting until healing is the appropriate conservative approach. 6

Step 3: Consider Patient-Specific Factors

The decision between operative and nonoperative management should weigh:

• Functional outcomes: At one year, there is no significant difference in functional scores (DASH) or pain between operative and nonoperative management in elderly patients, though operative management shows better grip strength. 6
• Complication rates: Operative management has higher 1-year upper-extremity-specific complication rates (307.5 vs 236.2 per 1,000 fractures), with stiffness being most common (16.0% operative vs 9.8% nonoperative). 7
• Radiographic outcomes: Operative management produces superior radiographic alignment at all follow-up intervals. 6

Critical Pitfalls to Avoid

• Do not use a removable splint for comminuted fractures. Removable splints are only appropriate for stable, minimally displaced buckle fractures—not comminuted patterns. 3, 5
• Do not assume all elderly patients need surgery. While surgical management is on the rise, conservative management with rigid casting remains valid for select patients, as minor limitations in range of motion and grip strength may not limit functional recovery at one year. 6
• Monitor for post-immobilization stiffness (the most functionally disabling complication) by initiating active finger motion exercises immediately, which does not adversely affect adequately stabilized fractures. 3

Recommended Approach

For a comminuted distal radius fracture in an elderly patient, perform closed reduction and apply a rigid cast (not a DonJoy brace), then reassess radiographically at 3 weeks. 3 If the fracture meets operative criteria (>3mm shortening, >10° dorsal tilt, or >2mm intra-articular step-off), surgical fixation should be strongly considered, weighing the patient's functional demands against the higher complication rates of surgery. 2, 6, 7