Osteoporos Int (2005) 16: S80–S84 DOI 10.1007/s00198-004-1808-x
R EV IE W
Treatment of osteoporotic distal radius fractures David Ring Æ Jesse B. Jupiter
Received: 16 October 2004 / Accepted: 28 October 2004 / Published online: 22 December 2004 Ó International Osteoporosis Foundation and National Osteoporosis Foundation 2004
Abstract Fracture of distal radius is most commonly an injury of the fit osteoporotic patient. As the population and health of older individuals continue to expand, osteoporotic distal radius fractures will become increasingly common. While many older patients have limited functional demands and can accept some deformity and wrist dysfunction, others remain very active into older age and desire optimal wrist alignment and function. The difficulty obtaining reliable fixation in osteoporotic bone presents a challenge to the surgeon that has been partially addressed by newer implants with screws that directly engage the plate, creating fixed angle bolts that have better fixation in osteoporotic bone. Decision-making is based upon a balance of the goals of the individual patient with the risks of intervention. Keywords Bone Æ Distal radius Æ External fixation Æ Internal fixation Æ Osteoporosis Æ Wrist
Introduction The distal part of the radius is one of the most commonly fractured bones. Fracture of the distal radial metaphysis is strongly related to osteoporosis. Simple falls onto an outstretched hand that would have led to a slight sprain or no injury at a younger age can cause a fracture in an older, osteoporotic individual. Higher energy falls that would have caused a more severe wrist sprain or a scaphoid fracture are also more likely to fail
at the distal radial metaphysis when there is osteoporosis. As older patients become more infirmed and less agile, they lose the ability to get the hand out to attempt to break their fall. As a consequence, they are more likely to break their hip. Fracture of the distal radius is typically a fracture of the relatively fit osteoporotic individual. The population of healthy older persons is expanding rapidly as a result of the large increase in births after World War II, as well as improvements in medical treatment and lifestyle [1, 2,3]. Many of these patients remain active well into their eighth and ninth decades, some of them pursuing activities such as golf or tennis on a daily basis [1]. As a result we can expect both a greater number of distal radius fractures as well as an increased demand for treatment that will provide adequate wrist function to return to these avocations. Displaced fractures of the osteoporotic distal radius result in bone impaction and fragmentation that can greatly diminish the stability of the fracture after manipulative reduction. Cast immobilization alone is often insufficient to maintain alignment of these fractures [4]. Operative fixation is also more difficult, since the fixation device cannot gain as strong or reliable a hold as it can in younger, stronger bone. Several techniques have been developed in an attempt to improve the operative treatment of the osteoporotic distal radius fracture.
The challenge D. Ring Æ J.B. Jupiter Harvard Medical School, Cambridge, MA, USA D. Ring (&) Æ J.B. Jupiter Department of Orthopaedic Surgery, Massachusetts General Hospital, Hand and Upper Extremity Service, Yawkee Center, Suite 2100, Fruit Str., Boston, MA 02114, USA E-mail:
[email protected]
Distal radius fractures in patients with osteoporosis present a substantial challenge to the orthopaedic surgeon, because these fractures are both more likely to be unstable and lose alignment after manipulation and casting as well as more difficult to treat operatively because the poor-quality bone is more difficult to control with internal and external fixation devices. Among the factors known to be associated with instability of the
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The first goal of distal radius fracture treatment is a hand that functions well. Although the hand is only occasionally directly injured, the swelling and pain associated with fracture of the distal radius, combined with treatment factors and patient anxiety or misunderstanding, can lead to permanent finger stiffness (Fig. 1). To diminish the risk of finger stiffness, the treating physician must pay substantial attention to the hand, particularly during early treatment. It is important
to avoid anything that may contribute to swelling, including tight casts or dressings, prolonged sling use, or failure to use and exercise the hand. The physician must encourage use of the hand, elevation, and motion. The hand should be incorporated into all light daily activities. If the physician is concerned that the fracture is not stable enough to support this light functional use, then another treatment method must be considered. The patient should never be cautioned against using the hand for fear of harming the fracture—that will lead to poor hand function. Compression of the median nerve should be identified and addressed. In older individuals there is only occasionally an acute carpal tunnel syndrome. Usually, after manipulative reduction and splinting in a relatively neutral position, any injury-related median nerve dysfunction will resolve. The wrist should never be splinting in more than slight flexion. On occasion, difficulty with exercises and pain with use of the hand may be related to an underlying carpal tunnel syndrome, and operative treatment can be considered. The second goal of treatment is functional forearm mobility. The forearm should be freed as soon as possible during treatment. While immobilization of the elbow and forearm might help control some fractures, this can prove disabling, particularly in relatively frail older patients. (Fig. 2) Specific forearm exercises must be taught, because we typically use our arms in a pronated position, and an effort must be made to regain supination. Forearm rotation can also be restricted by deformity of the distal radius, but older patients with fractures related to low-energy injuries demonstrate substantial tolerance for deformity in this regard. Visible deformity is usually a minor concern for older-aged patients. The clinically apparent deformity is
Fig. 1 Tight casts or dressings can contribute to stiffness and dysfunction in the hand. When faced with swelling like this, the treating surgeon should either place a looser dressing and accept malunion or provide operative stabilization so that a constrictive dressing is not necessary
Fig. 2 Bulky splints or casts that immobilize the elbow and forearm are very disabling, particularly in feeble older patients. For this reason, there is little advantage to above-elbow immobilization in the treatment of osteoporotic distal radius fractures
fracture (likelihood of loss of reduction after closed manipulation), most are associated with older age. Lafontaine and colleagues [5] found the risk factors for loss of reduction to be: (1) age over 60, (2) substantial initial deformity (greater than 20° dorsal tilt of the articular surface on the lateral radiograph or greater than 5 mm shortening by ulnar variance on the posteroanterior radiograph), (3) dorsal comminution, (4) fracture of the ulna, and (5) a displaced articular fracture. Younger patients with widely displaced fractures are more likely to have stout cortices, which can be realigned, whereas older osteoporotic patients will have a large bone void after reduction of the fracture where the osteoporotic bone has been compressed. Current implants incorporating angular stable screws (screws that engage the plate via threads forming fixedangle blades) have improved the ability to gain a reliable hold of osteoporotic bone. Decision-making for operative vs non-operative treatment is therefore based upon a balance of the risks and benefits for each individual patient, and the patient is involved in the decisionmaking process.
Goals of treatment
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often much less than the radiographic deformity. Operative treatment cannot eliminate deformity. Wrist flexion and extension may be the most difficult aspect of recovery to predict and control after a fracture of the distal radius. Articular fractures seem to be associated with a diminished wrist flexion arc. This can also be related to deformity, since it will be more difficult to flex the wrist if the bone is healed in a substantially extended position. Most patients can function well in spite of the losses of flexion and extension that accompany a fracture of the distal radius [6]. Grip strength can reflect the alignment of the wrist and the carpus as well as any underlying source of pain such as a mal-aligned articular fracture and arthritis. An important goal of treatment is the avoidance of complications. In particular, complications associated with operative treatment can negate any gains made by improving the radiographic alignment of the fractured distal radius. Injuries to the radial sensory nerve, dorsal ulnar cutaneous branch of the ulnar nerve, or the median nerve and its palmar cutaneous branch can lead to painful neuromas and even precipitate a chronic regional pain syndrome. Implants can irritate and even rupture tendons, particularly implants with a sharply cut edge [7,8]. Operative treatment causes additional trauma, swelling, scarring, and pain, all of which can contribute to stiffness of the hand, forearm, and wrist. In general, the wrist is similar to the hand, in that it is often preferable to use the least-invasive method that can achieve stable fixation in order to limit this operative trauma. Infection is commonplace with wires that penetrate the skin, but deep infection and osteomyelitis are unusual. Nonunion is unusual, but not unheard of [9,10], and may be associated with inadequate immobilization or operative fixation in a distracted position.
Non-operative treatment Abraham Colles’ oft-quoted statement—which can be paraphrased: Wrist function is not related to wrist deformity—is most applicable to fractures in older-aged osteoporotic patients with low-energy injuries [6]. There is consensus that a relationship exists between wrist deformity and wrist function that is more notable in younger, higher-demand patients with higher energy injuries. The better adaptation of older-aged patients to deformity of the distal radius remains incompletely understood but may relate to the relatively lower energy of the injury, potential differences in the soft tissues and scarring in older patients, or simply their lower functional demands. In a recent article, Young and colleagues reported good functional results overall, with poor relationship to radiographic measures of deformity, in 25 patients greater than 60 years of age with limited functional demands [6]. The exception to this was intra-articular deformity, which accounted for some of the worst functional results.
If the surgeon and patient elect to proceed with nonoperative treatment of a displaced fracture, they are making the decision to accept deformity. Even after an excellent manipulative reduction, gradual settling of unstable fractures is the rule. Factors that have been associated with instability of displaced fractures of the distal radius include: (1) age over 60, (2) initial displacement of greater than 20° dorsal angulation, (3) dorsal impaction and comminution of the metaphyseal bone, (4) comminution extending to the volar metaphyseal cortex, and (5) an associated fracture of the ulnar styloid or ulnar head and neck [5]. In a recent clinical trial comparing finger trap (112 patients) with manipulative reduction (111 patients) of fractures of the distal radius, the most notable finding was that only around 30% of patients maintained an acceptable radiographic reduction at 5 weeks after injury [4]. Given the fact that cast or splint immobilization cannot be relied upon to control alignment of the unstable osteoporotic fracture, these treatments should be used to provide comfort and support while minimally impacting function. The cast or splint should be relatively light and in some cases can be removable. It should not be tight and should not hinder digit or forearm motion.
Operative treatment Osteoporotic distal radius fractures challenge standard fixation techniques [11]. Internal and external fixation devices have a much weaker hold in osteoporotic bone that is more likely to loosen and less likely to maintain fracture alignment. Techniques of percutaneous pinning are a good example of this. Percutaneously inserted Kirschner wires rely substantially on the fixation achieved in the cortex of the proximal fragment. In the Kapandji technique of pinning distal radius fractures, this is the only fixation point of the pin, as the more distal portion of the pin is used to lever open the fracture site [12]. Particularly in osteoporotic individuals, this proximal cortex provides relatively limited fixation. Suggestions for improving the security of the fixation have included the use of concomitant external fixation (so-called augmented external fixation [12,13]), the use of bone graft or calcium phosphate cements [14], or the use of special cones rather than pins when using the Kapandji technique [15]. Calcium phosphate cements have not been as useful as initially hoped. It can be difficult to prepare the void created by the impacted metaphyseal bone. As a result, a small portion of cement is injected and the fracture can actually collapse around the cement if ancillary percutaneous pin fixation is not used, or even after the pins are removed. The drawbacks of the use of these cements, combined with their expense, have limited their use. The relatively large threaded pins (2.0–4.0 mm in diameter) used to apply an external fixation frame provide a better hold in osteoporotic bone, but do fail on
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occasion, sometimes with the entire frame pulling out of the bone. In nearly all patients with osteoporosis and relatively simple fracture patterns, external fixation with supplemental pins will provide adequate fixation. The use of non-bridging external fixation can provide better control of the distal fracture fragments [16]; however, this is also the weakest bone. It has been emphasized that it is critical to gain purchase in the relatively stout volar cortex of the distal fragment [16]. Internal fixation has become more popular recently. While the argument that stable internal fixation can allow for earlier wrist motion and therefore better results has yet to be substantiated, there are fractures that are difficult to control without internal fixation (such as fractures involving a coronal split in the lunate facet of the distal radius [17]) and some for which internal fixation is agreed to be the best treatment method, such as volar shearing fracture of the articular surface (Barton’s fracture) [18,19]. Standard screws rely on engagement or purchase of the bone by the threads of the screw. Diminished bone density greatly diminishes the function of standard screws [20]. As a result surgeons have been wary of using internal fixation for osteoporotic fractures of the distal radius. Another fixation technique that has proved unpredictable in osteoporotic bone is the so-called pinplate. With this technique a small plate is used to support a standard Kirschner wire [21]. Frequent users of this technique have become less enthusiastic about its use for osteoporotic fractures, because the fractures have a tendency to settle and the Kirschner wires then back out of the plate and become prominent. The use of screws that lock to the plate (via threads in the plate holes and threads on the screw heads) have greatly facilitated internal fixation of osteoporotic bone and are now being used in the distal radius. These are a direct evolution from the use of blade plates [11,22] and then Schuhli washers [23]. Fixed-angle or angular stable screws do not rely on engagement of screw thread and bone. They act like fixed blades supporting the surrounding bone. They have improved the fixation of osteoporotic nonunions of the humeral diaphysis [11] and other osteoporotic fractures and fracture sequelae. Some plates have fixed-angle distal screws only [22,24], whereas others have the option for threading all of the screws into the plate. Some plate designs feature fixedangle blades in the distal part of the plate [25]. Other techniques use fixed-angle wire forms [21]. Another useful technique is to use fixation in multiple planes [26,27]. This can be achieved either with dorsal and volar plates for complex fractures, with plates placed at relatively orthogonal angles, or with so-called fragmentspecific internal fixation with specific plates for the radial styloid, dorsal lunate and volar lunate facets [21]. The use of these techniques has improved the ability to provide predictable internal fixation of fractures in older-aged osteoporotic individuals. We recently reviewed the use of internal fixation in 20 patients aged 60 or greater, with an average age of 68 (range 60 to 81)
[28]. There were no cases of fixation failure. One patient had a tendon rupture related to the plate, and several patients had plate removal for tendon irritation, pointing out the relative drawbacks of internal fixation. However, when the fracture merits internal fixation and the patient desires optimal wrist function, reliable internal fixation of osteoporotic fractures of the distal radius is possible.
Decision-making Most infirmed and very low-demand patients are treated non-operatively. Active patients are offered the option of operative treatment to attempt to improve the alignment of the distal radius and thereby try to improve the function of the wrist. The type of operative treatment varies according to the pattern of the fracture and the preferences of the patient and the surgeon. Currently, most of the variations observed in practice can be ascribed to these preferences, as there is very limited data to help guide decision-making.
Conclusions Adequate wrist function can often be obtained by accepting deformity and treating the unstable, osteoporotic distal radius fracture in a cast. On the other hand, the population of healthy older-aged people is growing and many patients request operative treatment in an attempt to maintain a high level of wrist function. Several techniques of internal and external fixation can be used successfully in these patients. In particular, the development of plates with fixed-angle screws has facilitated internal fixation of osteoporotic fractures.
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