What is the best course of treatment for an older adult patient presenting with a distal end radius fracture, potentially with osteoporosis?

Treatment of Distal Radius Fractures in Older Adults

For older adults with distal radius fractures, treatment depends on fracture displacement: non-displaced or minimally displaced fractures should be treated with removable splinting for 3 weeks, while displaced fractures requiring surgical fixation should be immobilized for only 1-3 weeks post-operatively to optimize functional recovery. 1, 2

Initial Assessment and Treatment Selection

Radiographic Criteria for Surgical vs Conservative Management

Obtain initial radiographs to assess:

• Radial shortening >3mm 1
• Dorsal tilt >10° 1
• Intra-articular displacement 1

If any of these criteria are present, surgical fixation is indicated rather than conservative management. 1 This is particularly critical in osteoporotic patients, as they face significantly increased risks of malunion, hardware failure, and surgical site infection compared to patients with normal bone density. 3

Conservative Treatment for Non-Displaced Fractures

For minimally displaced fractures:

• Use removable splints rather than rigid casts 1
• Immobilize for 3 weeks 1, 4
• Obtain radiographs at 3 weeks to confirm healing and again at cast removal 1

The evidence strongly favors shorter immobilization periods, with 14 of 16 studies in a recent systematic review concluding that early mobilization produces equal or better outcomes than prolonged immobilization. 4

Post-Operative Management After Surgical Fixation

Immobilization Duration

Limit post-operative immobilization to 1-3 weeks maximum following volar plate fixation. 2 A high-quality 2018 randomized controlled trial demonstrated that both 1-week and 3-week immobilization groups achieved significantly better function scores, wrist extension, and flexion compared to 6-week immobilization at the 6-week mark. 2 While these differences equalized by 3-6 months, the early functional advantage and absence of increased complications make shorter immobilization preferable. 2

For older patients specifically (>70 years), early mobilization produces statistically significant better functional outcomes at 6 weeks without any increased risk of secondary dislocation. 5

External Fixation Considerations

If external fixation is used:

• Limit the duration of fixation to minimize complications 6
• Avoid prolonged fixation beyond 3 weeks when possible, as studies show poorer outcomes with extended external fixation 6
• Do not overdistract the wrist, though specific parameters cannot be definitively recommended due to limited evidence 6

Rehabilitation Protocol

Immediate Post-Diagnosis

Begin active finger motion exercises immediately following diagnosis or surgery 1 to prevent finger stiffness, which is one of the most functionally disabling complications of distal radius fractures. 1 Finger motion does not adversely affect adequately stabilized fractures. 1

After Cast Removal

• Early wrist motion is not routinely necessary following stable fracture fixation 1
• Implement a standardized education and exercise program for 6 weeks after immobilization removal 2

Adjunctive Treatments

Consider vitamin C supplementation for prevention of disproportionate pain (moderate recommendation strength). 6, 1 This represents the strongest adjunctive recommendation from AAOS guidelines.

Ultrasound and/or ice are options for adjuvant treatment, though evidence supporting these modalities is weak. 6, 1

Special Considerations for Osteoporotic Patients

Patients with osteoporosis or osteopenia face significantly elevated risks:

• Increased malunion rates (statistically significant at 3 and 12 months) 3
• Higher hardware failure rates 3
• Increased surgical site infection risk 3
• Greater likelihood of hardware removal 3

These patients require more intensive monitoring and consideration of bone health optimization, though the evidence does not support avoiding surgical fixation when indicated. 3

Associated Injuries

Ulnar Styloid Fractures

Concomitant ulnar styloid fractures do not require routine fixation. 6 Available evidence shows no difference in outcomes between fixation and non-fixation of associated ulnar styloid fractures, though patients with these injuries may have slightly poorer overall outcomes regardless of treatment. 6

Critical Pitfalls to Avoid

• Do not immobilize for 6 weeks post-operatively - this produces worse short-term functional outcomes without any long-term benefit 2
• Do not delay finger motion exercises - finger stiffness is highly disabling and preventable 1
• Do not skip radiographic follow-up at 3 weeks - this is essential to confirm maintenance of reduction 1
• Do not use prolonged external fixation - duration should be minimized to reduce complications 6
• Monitor osteoporotic patients more closely for complications, as their risk profile is substantially elevated 3