What is the recommended management approach for distal radius fractures in patients of different age groups?

Management of Distal Radius Fractures by Age Group

For geriatric patients ≥65 years old, non-operative treatment with casting or splinting should be the default approach regardless of how the fracture looks on X-ray, while patients <65 years require operative fixation when post-reduction films show radial shortening >3mm, dorsal tilt >10 degrees, or intra-articular step-off >2mm. 1

Geriatric Patients (≥65 Years Old)

Primary Treatment Approach

• Non-operative management is the standard of care for all geriatric distal radius fractures, as operative treatment does not improve long-term patient-reported outcomes compared to casting 1
• This recommendation applies regardless of radiographic parameters—even fractures that look "bad" on X-ray should be treated conservatively 1
• Research confirms this approach: operative management in elderly patients results in higher 1-year complication rates (307.5 vs 236.2 per 1,000 fractures) with no functional benefit 2

Immobilization Strategy

• Use removable splints for minimally displaced fractures, which provide adequate stability while allowing hygiene and skin care 3
• Rigid casting is preferred for displaced fractures requiring better immobilization 3
• Duration: typically 4-6 weeks with radiographic follow-up at 3 weeks and at immobilization removal 3

Critical Pitfall to Avoid

• Do not operate on geriatric patients based solely on radiographic appearance 1
• While operative treatment achieves better radiographic parameters (volar tilt, radial inclination, ulnar variance), these improvements do not translate to better functional outcomes 4
• Operative management carries significantly higher risks of stiffness (16.0% vs 9.8%), complex regional pain syndrome (9.9%), median neuropathy (8.0%), and implant complications (3.8%) 2

Non-Geriatric Patients (<65 Years Old)

Operative Indications

Surgical fixation is indicated when post-reduction radiographs demonstrate any of the following: 1

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

Operative Technique Selection

• Any fixation method (volar locking plates, external fixation, percutaneous pinning) can be chosen based on surgeon preference and fracture pattern, as no technique shows superior long-term outcomes 1
• Volar locking plates offer the advantage of faster return to function within the first 3 months, though long-term outcomes at 1 year are equivalent to other methods 1
• For complex type C fractures in the 65+ age group who do require surgery, both volar locking plates and external fixation with K-wires yield comparable functional outcomes and complication rates 5

Universal Management Principles (All Ages)

Pain Management

• Implement multimodal, opioid-sparing analgesia including local anesthetics, NSAIDs, acetaminophen, ice, elevation, compression, and cognitive therapies 1
• Consider vitamin C supplementation for prevention of disproportionate pain 3

Rehabilitation

• Initiate active finger motion exercises immediately following diagnosis to prevent stiffness, which is the most functionally disabling complication 3
• Finger motion does not adversely affect adequately stabilized fractures 3
• Home exercise programs are equivalent to supervised therapy, so patient preference should guide this decision 1
• Early wrist motion is not routinely necessary following stable fracture fixation 3

Follow-Up Protocol

• Radiographic evaluation at approximately 3 weeks post-treatment 3
• Repeat imaging at time of immobilization removal to confirm adequate healing 3
• Monitor for complications including stiffness (most common at 11.5% overall), complex regional pain syndrome, and median neuropathy 2

Key Clinical Pearls

The evidence strongly diverges based on age: while younger patients benefit from anatomic restoration through surgery when displacement criteria are met, elderly patients experience no functional benefit from operative treatment despite achieving better radiographic parameters 1, 2, 4. The higher complication burden in geriatric operative cases (particularly stiffness, nerve injury, and implant problems) combined with equivalent functional outcomes makes non-operative treatment the clear choice for this population 2.