Extra-articular distal end radius fractures in elderly treated conservatively- functional outcome

Introduction

An ageing population is associated with an increase in the frequency of distal radius fractures, an orthopaedic problem that affects many people. Orthopaedic surgeons have special concerns while treating some types of fractures, including those involving the distal end of the radius that occur outside of the joint.1 An ever-shifting tendency towards conservative methods, prioritising functional results above surgical measures, has emerged in the ongoing debate over the management of these fractures. Fractures caused by osteoporosis and age-related deterioration are becoming more common as the world's old population keeps growing.2 Distal end radius fractures make up a large percentage of these fractures and provide major obstacles to treatment methods and functional results in the long run.3 There has been an upsurge in interest in conservative treatment methods for extra-articular fractures, which are defined as those that do not involve the joint surface.

Cast immobilisation, physical therapy, and close observation are examples of non-surgical treatments for extra-articular distal end radius fractures.4 This method is designed to help older patients who may have other health conditions that make surgery more risky reach fracture union and functional independence as soon as possible with as few problems as possible. Considerations such as fracture features, patient age, co-morbidities, and functional demands have a role in the choice to conservatively treat extra-articular distal end radius fractures. Orthopaedic practitioners must have a thorough understanding of the specific difficulties associated with these fractures as well as the effects of conservative treatment on functional results in order to make well-informed judgements that are specific to their senior patients' requirements.5

Significance of the Study

The study's importance rests in its implications for the treatment of the ageing population and related fractures, namely extra-articular distal end radius fractures in the elderly treated conservatively. To optimise patient care, it is essential to evaluate the functional results of conservative therapy for distal radius fractures, which are more common in the elderly. To help doctors in their decision-making processes, this research adds to the medical community by giving important insights into the efficacy of non-surgical methods. By looking at functional outcomes, healthcare providers can learn about the long-term effects on patients' life and the pros and downsides of conservative treatment options. In the end, this study helps enhance the treatment that older adults with distal radius fractures receive, which leads to better results for patients and overall health.

Research Methodology

From December 2021 through June 2023, researchers from the Orthopaedics Department at Thrissur Govt. Medical College in Thrissur carried out a prospective, randomised study. The local ethics committee gave its blessing, and sixty patients (all 50 and up) with a distal end radius extra articular fracture that was displaced but stable and had no joint incongruity gave their informed consent. In addition to patients having a history of wrist or forearm fractures, we did not include individuals with open fractures, dorsal comminution fractures, congenital or other forearm abnormalities, dorsal tilts more than 20 degrees, or intra-articular distal end radius fractures. Cast immobilisation and closure reduction were performed on thirty individuals. Thirty-one patients had percutaneous K wires placed for closed reduction.

Closed reduction with conventional cast immobilisation was performed on patients under regional or general anaesthesia with C-arm guidance in the operating room. Under the influence of anaesthetic, Agee's manoeuvre was used to accomplish reduction. A cast was placed below the elbow, beginning at the metacarpophalangeal joints and finishing at the proximal portion of the forearm (while sparing the thumb), after a soft roll was wrapped around the patient. This immobilised the patient. A patient had to be painted and draped before two crossed K wires could be introduced under C arm guidance to cross fracture lines in both planes, allowing for closed reduction with percutaneous pinning. Dressing the patient followed the cutting and bending of both K wires.

The patient's hands were raised for 24 hours after the procedure, and intravenous antibiotics and analgesics were given. After that, antibiotics, pain relievers, and calcium supplements were taken orally. The group that had closure reduction and cast immobilisation, in contrast, did not receive antibiotics. Patients were then discharged and re-evaluated at the end of the first, second, fourth, sixth, and twelfth weeks. At every checkup, we took AP and lateral X-rays in addition to taking notes and doing a clinical evaluation. A Visual Analogue Scale was used to evaluate each group. Saito charts for pain and deformity were used to evaluate both groups. The success of each fracture was evaluated using Lindstrom's Criteria for Anatomical End Result (LCAER) and Lindstrom's Criteria for Functional End Result (LCFER). We used XLSTAT, an unpaired student's t-test.

Results

To address the increasing number of older people and the related fractures, this study focuses on conservatively treating extra-articular distal end radius fractures in this group. Thirty patients underwent cast immobilisation and closure reduction. Thirty patients underwent closed reduction with percutaneous K wires.

The gender breakdown of the patients who were part of the K-wire group and the cast group is presented in Table 1.

Both the group that utilised casts and the group that employed K-wires were able to demonstrate a wide range of mobility, as documented in Table 2. Among the members of the cast, the average age was 63.43 years old altogether. It was found that the K-wire group had an average age of 62.16 years, and the p-value for this group was just 0.6097.

It is clear from looking at Table 3 that both the cast group and the K-wire group had trouble. The Visual Analogue Scale (VAS) was utilised in order to assess both of the populations. According to the VAS, the K-wire group had a score of 4.7, whereas the cast group had a score of 5.6 (P = 0.007).

A breakdown of the Saito scores for both the cast and K-wire groups can be found in Table 4. The scores may be divided into two separate categories, as shown in the table. Excellent and respectable. For the purpose of drawing conclusions, the data from both groups are presented in Table 4, which makes use of the four levels of Lindstrom's Criteria for Anatomical End Result (LCAER). The results of patients in both groups are presented in Table 4, which pertains to Lindstrom's Criteria for Functional End Result (LCFER). The average amount of radial length that was lost in patients who had closed reduction and cast measures 6.83 millimetres. It was shown that patients who had closed reduction with a K-wire experienced an average radial length loss of 3.8 millimetres, with a p-value that was lower than 0.0003.

Discussion

When treating elderly individuals, it is important to keep in mind the unique challenges posed by distal end radius fractures that develop outside of the joint. Recent research has shown that conservative therapy, an alternative to surgical treatment, may be an option for these fractures. Common elements of this approach include applying a cast or splint to the injured region, prescribing pain medication, and participating in physical therapy. The decision to choose for conservative therapy is influenced by factors such as the patient's age, co-morbidities, fracture stability, and functional requirements. Research demonstrating promising functional outcomes with conservative therapy in the elderly has brought attention to the importance of personalised treatment. Stabilising a fracture by immobilisation helps the healing process along more smoothly.

An increased incidence of distal end radius fractures, a condition associated with all of the risk factors for osteoporosis, is seen in the elderly. In a two-year prospective study following 113 patients. External fixation and percutaneous pinning fixation were superior to traditional cast immobilisation. In contrast, a randomised clinical trial conducted by "Stoffelen" showed that the results for patients treated with casting vs percutaneous pinning methods were the same.12, 13 Distal end radius fractures treated with K-wire pinning fixation are more quickly and with less technical difficulty than those treated with more complex fixation procedures. It is less invasive than open reduction, which means less harm to soft tissues, and it works well with cast immobilisation.

Problems with this approach include the potential for pin tract infection, incorrect reduction of fractures, and unstable fixation as compared to plating procedures. The research conducted by "Rosenthal" et al. shown that intrafocal pinning worked better than both closed reduction and cast. Stiffness in the fingers and wrists is a very unusual side effect of external treatment for Colles' fractures.14, 15

In terms of radial length loss, range of motion, and VAS ratings, our study indicated that the group that had closed reduction K-wire fixation had improved results. A statistical analysis revealed these disparities to be substantial. This was also clearly shown when comparing the two groups using Lindstrom's criteria results and the Saito chart. After the removal of the K-wires, a pin tract infection that had developed in 13% of patients resolved itself. The operation had no other major adverse effects than this.

Results in function can be positive for older individuals with extra-articular distal end radius fractures when conservative treatment is tailored to their specific needs. Thanks to a well-rounded assessment of fracture characteristics, patient concerns, and careful monitoring, this approach is effective in providing an alternative to surgical methods in some cases.

Conclusion

Functional results are favourable when older patients with extra-articular distal end radius fractures are treated conservatively. Successful outcomes can be achieved without the dangers of surgery by utilising this method, which focuses on non-invasive treatments including casting, bracing, and rehabilitation. The study highlights the significance of tailoring treatment approaches to each patient by taking their age, comorbidities, and fracture characteristics into account. A cautiously supervised conservative strategy can enhance function and quality of life for older adults with distal end radius fractures, despite the limitations provided by aging-related variables such osteoporosis. Compared to closed reduction and cast immobilisation, closed reduction with percutaneous K-wire fixation is a safer, better, and simpler approach to maintain reduction in displaced, distal end radius fractures with few sequelae. The results stress the need of individualised rehabilitation plans to maximise functional outcomes in this particular group of patients and call for a nuanced approach to decision-making that weighs the pros of conservative therapy against the risks of surgery.

Author Contribution

All authors contributed equally to this work. And all the authors have read and approved the final version manuscript

Source of Funding

The authors received no financial support for the research, authorship and/ or publication of this article.

Conflicts of Interest

The authors declare that we have no conflict of interest.