What is the appropriate management for a 79-year-old female with a distal radius fracture?

From the Guidelines

This patient has a distal radius fracture that requires prompt orthopedic referral for definitive management, as recommended by the American Academy of Orthopaedic Surgeons and American Society for Surgery of the Hand in their 2022 clinical practice guideline summary 1. The patient should have her wrist immobilized in a splint, continue ice application for 15-20 minutes every 2-3 hours, and maintain elevation of the affected limb above heart level to reduce swelling. Pain management can continue with acetaminophen 650mg every 6 hours and ibuprofen 400-600mg every 6 hours as needed, alternating between the two medications. The patient should be advised to remain non-weight bearing on the affected wrist until evaluated by orthopedics, ideally within 3-7 days. Given her age, a bone density scan should be considered to evaluate for underlying osteoporosis, as distal radius fractures in elderly patients often occur with relatively minor trauma and may indicate decreased bone mineral density, as suggested by the EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures 1. The patient should be monitored for complications such as compartment syndrome (increasing pain, paresthesias, pallor) and instructed to return immediately if these symptoms develop. Depending on the fracture pattern and displacement, treatment options may range from casting to surgical fixation, which will be determined by the orthopedic specialist. It is essential to follow the most recent and highest quality guidelines, such as the 2022 American Academy of Orthopaedic Surgeons and American Society for Surgery of the Hand clinical practice guideline summary, to ensure the best possible outcomes for the patient 1. Early finger motion is crucial to prevent edema and stiffness after casting or surgery for distal radius fracture, as emphasized in the EULAR/EFORT recommendations 1. The use of removable splints may be an option for minimally displaced distal radius fractures, as suggested by the 2010 treatment of distal radius fractures recommendation, but this should be determined by the orthopedic specialist 1.

From the Research

Patient Presentation and Diagnosis

• The patient is a 79-year-old female who presented to urgent care after falling into a raised flower bed and landing on her left wrist.
• She reports increased swelling and pain to the wrist and forearm, and denies any other injury, loss of consciousness, or anticoagulant use.
• X-ray results confirmed a distal radius fracture.

Management of Distal Radius Fractures

• According to 2, distal radius fractures can be managed non-operatively or surgically, depending on the severity of the fracture and patient comorbidities.
• Non-operative management may include immobilization with or without reduction, while surgical options include closed reduction and application of a cast, percutaneous K-wires, open reduction and internal fixation with plates, or external fixation.
• Early mobilization is recommended to prevent stiffness, and median nerve compression is a common complication to watch for 2.

Osteoporosis Prevention and Treatment

• The patient's distal radius fracture may be an opportunity to diagnose and treat osteoporosis, as fragility fractures of the distal radius are common in patients with osteoporosis 3.
• However, studies have shown that fewer than 25% of patients with fragility fractures of the distal radius receive prescriptions for calcium/vitamin D supplementation and undergo DEXA scans 3.
• Women are more likely to receive osteoporosis treatment than men, but many patients do not receive adequate treatment, highlighting the need for improved healthcare services to prevent future fractures 3, 4.

Treatment Options and Controversies

• The treatment of distal radius fractures is not without controversy, and different approaches may be taken depending on the severity of the fracture and patient factors 5.
• Some studies suggest that percutaneous pinning and open reduction may be effective treatment options, while others emphasize the importance of early mobilization and rehabilitation 6, 5.