Surgical Criteria for Distal Radius Fractures
For patients under 65 years of age, surgical fixation is indicated when post-reduction radiographs demonstrate radial shortening >3mm, dorsal tilt >10 degrees, or intra-articular displacement/step-off >2mm, while patients 65 years and older should generally be managed non-operatively as surgery does not improve long-term patient-reported outcomes despite better radiographic parameters. 1
Age-Based Surgical Decision Making
Non-Geriatric Patients (Under 65 Years)
The 2022 AAOS/ASSH guidelines provide moderate evidence supporting operative fixation in patients under 65 when any of the following post-reduction criteria are met: 1
- Radial shortening >3mm
- Dorsal tilt >10 degrees
- Intra-articular displacement or step-off >2mm
This recommendation is based on one high-quality and 26 moderate-quality studies demonstrating improved outcomes with surgical intervention in this population. 1
Geriatric Patients (65 Years and Older)
Strong evidence demonstrates that surgical fixation does not lead to improved long-term patient-reported outcomes compared to non-operative treatment in patients over 65. 1 This is supported by two high-quality studies and 11 moderate-quality studies consistently showing that while radiographic parameters improve with surgery, functional outcomes remain equivalent. 1
Critical Nuance: Functional Demand Over Chronologic Age
The age cutoff of 65 years serves as a proxy for functional demand, not an absolute threshold. 1 A patient-centered discussion should assess individual values, preferences, and functional requirements to guide treatment decisions aligned with functional demands rather than age alone. 1 A highly active 70-year-old may benefit from surgery, while a sedentary 60-year-old may not.
Surgical Technique Selection
No difference exists in long-term outcomes between fixation techniques for complete articular or unstable distal radius fractures, though volar locked plating provides earlier functional recovery at 3 months. 1 This strong evidence is based on six high-quality studies comparing various methods including:
- Volar locked plating
- Dorsal plating
- External fixation
- Percutaneous pinning
- Fragment-specific fixation
By one year post-injury, all techniques demonstrate equivalent patient-reported outcomes. 1
Common Pitfalls to Avoid
Do not operate on geriatric patients based solely on radiographic parameters. 1 The evidence clearly shows that achieving anatomic reduction in elderly patients does not translate to functional benefit, making surgery potentially unnecessary morbidity.
Do not assume all displaced fractures require surgery. 1 The specific post-reduction measurements (not initial displacement) determine surgical candidacy in appropriate-age patients.
Avoid using chronologic age as the sole determinant. 1 A 66-year-old manual laborer may warrant different consideration than a 63-year-old with minimal functional demands.