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NIH Public AccessAuthor ManuscriptHand Clin. Author manuscript; available in PMC 2013 Ma 01.

Published in !inal edited !orm as"Hand Clin. 2012 Ma ; 2#$2%" 113&12'. doi"10.101()*.hcl.2012.02.001.

The Epidemiology of Distal Radius Fractures

Kate W. Nellans, MD, MP1, E!an Ko"als#i, $%2, and Ke!in &.

&hung, MD, M%3

1Hand Fellow, University o Michi!an Health "yste#, "ection o Plastic"ur!ery

2$esearch Associate, University o Michi!an Health "yste#, "ection oPlastic "ur!ery

3Proessor o "ur!ery, "ection o Plastic "ur!ery, Assistant %ean or FacultyAairs,&heUniversity o Michi!an Medical "chool

'(stract+istal radius !ractures are one o! the most common tpes o! !ractures, accountin- !or around 2'o! !ractures in the pediatric population and up to 1# o! all !ractures in the elderl a-e -roup.Althou-h the pediatric and elderl populations are at the -reatest ris/ !or this in*ur, distal radius!ractures still have a si-ni!icant impact on the health and ellbein- o! oun- adults. +ata !romthe past 0 ears has documented a trend toards an overall increase in the prevalence o! thisin*ur. or the pediatric population, this increase can li/el be attributed to a sur-e in sportsrelated activities. 4he -roth o! the elderl population and a rise in the number o! active elderlare directl responsible !or the increase seen in this a-e -roup. 5nderstandin- the epidemiolo- o!this !racture is an important step toards the improvement o! the treatment strate-ies and

preventative measures hich tar-et this debilitatin- in*ur.

Key"ords

distal radius !racture; epidemiolo-; incidence; !ra-ilit !racture

)ntroduction

+istal radius !ractures are one o! the most common tpes o! !ractures, ith over (0,000cases reported durin- 2001 in the 56 alone.1 or reasons not !ull understood, and li/elmulti!actorial, the incidence o! this !racture appears to be on the rise in the 56 andabroad.2&' Man o! the societal e!!ects o! these !ractures e7tend beond the si-ni!icantmedical costs, includin- decreased school attendance, lost or/ hours, loss o! independenceand lastin- disabilit. ra-mented care and codin- discrepancies can ma/e accountin- !or

the true number o! these !ractures di!!icult, li/el underestimatin- the rates tpicall 8uotedin the literature. 9hen anal:in- the incidence o! distal radius !ractures, there are threema*or populations to consider" children and adolescents, oun- adults, and the elderl. 4he

pediatric and elderl populations are both considered at hi-h ris/ !or this in*ur, and thecontributin- !actors ill be e7amined in this paper. In addition to the 3 main a-e -roups,

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-ender and ethnicit ma also be considered distinct ris/ !actors ithin each o! thesepopulations. 5nderstandin- the epidemiolo- o! distal radius !ractures can help phsicianschoose the most appropriate treatment options !or the !racture, as ell as e!!ectivel tar-et

preventative measures toards atris/ populations.

Population )ncidence

*!erall

Chun- and 6pilson used data !rom the National Hospital Ambulator Medical Care 6urve$NHAMC6% database and determined that 1.' o! all emer-enc department visits ere dueto hand and rist !ractures. adius and ulna !ractures consisted o! o! these !ractures.1

4his stud corresponds to a stud b Barsen and Bauritsen shoin- that distal radius!ractures accounted !or 2.' o! all emer-enc department visits.( 4hese numbers var moreidel in earlier reports, but still represent a hi-h incidence rate. In 1>(2, an analsis o!!ractures in 6eden documented the number o! distal radius and ulna !ractures to be as hi-h@' o! all !orearm !ractures.@ A stud b =noelden et al. in 1>( !ound 32 o! all!ractures seen in omen over the a-e o! 3' in the distal end o! the radius.#

Trends of increasing incidence

Current and past clinical data point to a rise in the incidence o! distal radius !ractures !or thepediatric, adult, and elderl populations in recent ears. 4his phenomenon has been a sub*ecto! debate as earl as the 1>(0s hen Al!!ram and Dauer published their report on theincreasin- occurrence o! distal radius !ractures in a lar-e 6edish cit.@ A stud !romochester, Minnesota !ound a 1@ increase in the incidence o! this in*ur over a 0 ear

period.2 4he incidence in 6eden almost doubled !or the elderl population over a 30 eartime span hen compared to previous data !rom the same location. +urin- the same stud

period as this increase, the incidence rates o! sha!t !ractures o! the radius and ulna remainedthe same, lendin- !urther validit to the increase in distal radius !ractures as a le-itimatetrend.> Althou-h there is no sin-le !actor responsible !or this phenomenon due to theabsolute prevalence o! distal radius !ractures, an individual contributin- !actor is bound tohave con!oundin- variables.

Man theories have been proposed to determine the source o! the increasin- rates o! distalradius !ractures, but studies correlatin- a speci!ic cause to the incidence o! this in*ur mustbe care!ull evaluated. 4he in!luence o! li!estle and environmental !actors on the ris/ andincidence o! distal radius !ractures has recentl been assessed to !urther e7amine the causes!or the increasin- rates. Ene stud !ound a 30 -reater ris/ !or a distal radius !racture inurban omen over rural omen.10 Althou-h the data indicated a si-ni!icant di!!erence

beteen ris/ !actors, it could not seem to determine the cause o! this discrepanc, even a!teranal:in- li!estle and health !actors. Ethers point to the impact o! epi-enetic in!luences onthe development o! diseases such as childhood obesit and osteoporosis as a basis !or theincreasin- incidence o! this !racture in di!!erent populations.11,12 It is possible that chan-in-cultural dietar habits ma be alterin- bone metabolism, a!!ectin- the overall incidence o!distal radius !ractures. Additionall, as the population a-es and individuals strive to remainactive, !ractures due to relativel minor traumas have increased.@ Ether theories ill be

discussed in !urther detail throu-hout the !olloin- sections.

&os

tsAs the incidence o! distal radius !ractures rises, the short and lon- term costs becomeapparent.

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upards o! F2 Dillion per ear.12 4his is not surprisin- considerin- the overall prevalence o!this in*ur. Chun- et al. recentl evaluated the costs that accompan this in*ur ith respectto the elderl communit. 4he !ound in 200@, Medicare paid F1@0 million in distal radius!racture related paments.1 Additionall, the pro*ected that the !uture burden o! Medicarecould be F20 million i! the current trend in the use o! internal !i7ation continues. 4hesecosts did not include an secondar e7penses associated ith this in*ur such as prescriptiondru-s, lost time at or/, and loss o! independence, hich ma be more si-ni!icant than the

direct costs. 4his data reveals the si-ni!icant socioeconomic costs incurred as a direct resulto! distal radius !ractures, and hi-hli-hts the importance o! anal:in- preventative measuresand treatment protocols !or individuals ho are at a hi-h ris/ !or or su!!er !rom this in*ur.

Pediatric )ncidence

Children and adolescents are at a particularl hi-h ris/ !or distal radius !ractures, in part dueto a rapidl developin- s/eletal structure. 6tudies have documented that up to 2' o!!ractures in children involve the distal end o! the radius.1'&1# A stud b Bandin estimatedthat until the a-e o! 1(, the ris/ o! -ettin- a !racture is 2 in bos and 2@ in -irls.1' Inthis analsis, !ractures o! the distal !orearm accounted !or appro7imatel 21 o! all!ractures in the pediatric population. 4he indirect costs o! this in*ur are incalculable interms o! medical costs, lost time !rom school, and even !uture or/ potential.

)ncreasing o!erall incidence

4he incidence o! distal radius !ractures in children appears to be risin-, but it is di!!icult toe7plain the e7act cause o! this stead increase over the past 0 ears $i-ure 1%.3,1>,20 6omestudies su--est this could be the result o! an overall increase in the participation o! sportsrelated activities in the pediatric population.3,12,1>,21 Putter et al !ound an increase in sportsrelated activities correlated ith an increase in sportsrelated distal radius !ractures $i-ure2%. In another stud, 23 o! all sports !ractures occurred in the distal part o! the radius.22

Hoever, Mathison and A-raal attest that this increase ma be due to an improved accessto care and better detection o! !ractures.21

'ge and $one $iology

6tudies have revealed the avera-e !racture incidence related to a-e to be hi-her in bos thanin -irls.12,1' In the 1>(0s, the pea/ rate o! !ractures o! the distal radius as !ound to occurdurin- the start o! pubert, beteen the a-es o! 10 to 1.@ A stud in 1>#> !ound the pea/a-e to be speci!icall beteen 11.'&12.' ears old !or -irls and 13.'&1.' ears old !or

bos,23 hile more recent data su--ests that !or -irls the pea/ a-e is anhere !rom #&11and !or bos !rom 11&1.1> 5sin- current data !rom the NHAMC6, Chun- and 6pilsonrecentl documented this pea/ !or the pediatric population, and noted a similar trend $i-ure3%. A!ter this pea/ rate o! occurrence, the !re8uenc o! distal radius !ractures conse8uentlloers, and is then onl e7ceeded b the incidence rates in omen '0 ears o! a-e andolder.23 Althou-h it mi-ht seem lo-ical to attribute the causes o! this pea/ rate durin-

pubert to an increase in phsical activit, it is /non that activit levels tend to decrease aschildren pro-ress throu-h pubert.2 ather, the pea/ rate o! !ractures appears to be closelcorrelated to the bone mineral densit and bone mineral content o! the distal radius durin-

the pubescent -roth spurt.

6tudies have con!irmed a lar-e dissociation beteen s/eletal -roth and minerali:ationdurin- pubert, hich ma account !or the increased !ra-ilit o! bones seen durin- this sta-eo! development.23,2'&2# In an earl stud on the sub*ect, =rabbe et al. !ound that durin- the

pubescent -roth spurt, children e7perience lar-e, sudden advances in linear development,or bone len-thenin-, concurrent ith ver small increases in bone mineral content.2' 4he

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process o! bone minerali:ation cannot /eep up ith the abrupt increase in ne bonedevelopment, resultin- in bones that are particularl susceptible to !racture. A!ter pubert,linear development be-ins to slo, and bone mineral content be-ins to increase rapidl,creatin- stron-er bones that are more resistant to trauma. an et al. !ound a statisticallsi-ni!icant hi-her proportion o! in*uries due to minor trauma in the 10&1 a-e -roup hencompared to the '&> a-e -roup.12 4his ma su--est that a ea/ened s/eletal structure due tolo rates o! bone minerali:ation durin- the adolescent -roth spurt leaves even a minor

trauma ith the potential to cause a distal radius !racture.

Additionall, some su--est there ma be a brie! period o! increased cortical porosit durin-the adolescent -roth spurt to allo !or e!!icient absorption o! calcium re8uired b the

bones durin- this rapid sta-e o! -roth.2> Prior to minerali:ation, the increased boneporosit ma contribute to the pea/ rate o! distal radius !ractures seen durin- this period o!rapid phsiolo-ical development.

+ender and Ethnicity

4he incidence rate o! distal radius !ractures is /non to be hi-her in bos than in -irls. Astud b an et al. demonstrated a statisticall si-ni!icant di!!erence beteen the incidencerates o! bos and -irls, ith ( o! all !ractures occurrin- in bos.12 Ether studies haveshon similar results.3,1',20,23 4here is no evidence su--estin- si-ni!icant ethnic di!!erences

in the rates o! pediatric distal radius !ractures. Ene lar-e stud !ound no si-ni!icantdi!!erence in the rate beteen urban and rural pediatric populations.1>

Mechanism of )nury

4he mechanism o! in*ur in distal radius !ractures in the pediatric population has been elldocumented. 4he main tpes o! activities causin- distal radius !ractures in children aresports, car accidents, and plain-. =hosla et al. !ound that !rom 1>>> to 2001, 10 o! all

pediatric distal radius !ractures in Elmsted Count occurred hile children ere usin-pla-round e8uipment.1> +ata !rom an et al. documented 30 o! distal radius !racturesresultin- !rom sports related in*uries in the 10&1 a-e -roup, hile sports ere responsible!or @ o! these !ractures in the 1'&1@ a-e -roup. 4he most common mechanism o! in*uras !all related, ith studies shoin- around #0 o! in*uries occurrin- in this !ashion.12,30

-oung 'dult )ncidence

4he incidence o! distal radius !ractures in the adult population is si-ni!icantl loer than inother a-e -roups.31 As a result o! this loer incidence, and the apparent random occurrenceo! !ractures in this lo ris/ -roup, little data is available on this population re-ardin- theepidemiolo- o! this in*ur. Hoever, even at a lo rate, the complications !olloin- thisin*ur can result in lastin- disabilit in previousl oun-, health individuals. Althou-hin!re8uent, these !ractures are still the most common in*ur in the oun- adult population.32

6ports and car accidents are /non to be one o! the most common causes o! distal radius!ractures in oun- adults.

+ender and Ethnic differences

esearch has shon that hite omen have hi-her rates o! distal radius !ractures inindividuals above the a-e o! (', a trend not apparent in oun-er adults.33,3 Dro-ren et al.!ound that in the a-e -roup o! 1>&>, men and omen had almost identical incidence rates.Hoever, hen loo/in- at the a-e -roup !rom 1>&(', omen had almost double the ratehen compared to men, li/el oin- to the onset o! osteoporosis in omen over '0 earsold.31 A stud b Chun- and 6pilson !ound that Caucasians represented #3 o! all !ractures

but also had the lar-est proportion o! emer-enc department visits.1 I! other ethnic

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minorities are less li/el to present themselves to the emer-enc room a!ter an in*ur thanCaucasians, this ma account !or the discrepanc in the published rates o! ethnic di!!erencesin distal !orearm !ractures.

Elderly )ncidence

+istal radius !ractures account !or up to 1# o! all !ractures in the over(' a-e -roup.3'

Numerous !actors contribute to this ris/, includin- architectural chan-es in the bone,increased activit levels, and metabolic bone disease. 4his !racture ill prove to be a strainto the medical sstem over the ne7t several decades due to the e7plosive -roth o! theelderl population.1

Most !ractures occurrin- in the elderl are the result o! trauma due to a lo ener- !orce,ith a !all !rom a standin- hei-ht the leadin- cause o! in*ur.3(,3@ Man o! the accidentscausin- these lo ener- !ractures occur as an individual tries to stop a !all ith a dorsalloutstretched hand. Bo bone mineral densithas been ell documented in elderl omen ho su!!er a distal radius !racture.0&' A

recent stud b Jen et al. !ound that decreased bone mineral densit as a better predictoro! the ris/ o! distal radius !ractures in omen than in men, but a si-ni!icant predictor in bothmen and omen once osteoporosis as dia-nosed.3

Claton et al. recentl documented the relationship beteen osteoporosis and the severit o!distal radius !ractures.( 4his stud indicated that less bone mineral densit as correlatedith more severe, intraarticular !ractures. It also revealed that a decrease in bone mineraldensit is related to an increase in the probabilit o! earl instabilit a!ter closed reduction,

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ith a (( chance in the osteoporosis -roup compared to onl a # chance in the normal-roup. Additionall, the !ound that the probabilit o! late carpal malali-nment as 3' inthe osteoporosis -roup but onl 2' in the normal -roup.

Pediatric *utcomes

'ge

In s/eletall immature individuals, anatomic reduction o! distal radius !ractures is usuallnot re8uired due to the potential !or -roth and remodelin-, and operative intervention isseldom arranted. 4his !racture is rarel intraarticular, alloin- !or initial imper!ectreductions to be elltolerated. It is accepted that distal !ractures have a more !avorable

pro-nosis than those in a more pro7imal aspect o! an e7tremit. Ebservational studiesindicate displacement o! ver distal !ractures in patients o! all a-es is better tolerated thanmore pro7imal malunions in even ver oun- children.@,#

Dased on lon-term !unctional outcomes o! malunions in pediatric !orearm !ractures,Noonan et al. made a series o! recommendations !or reduction in pediatric patientspresentin- ith this in*ur. or patients less than > ears old, reduction could be acceptedith complete displacement $baonet apposition% and up to 1cm o! shortenin-, 1' de-rees o!an-ulation, and ' de-rees o! malrotation, ithout resultin- in !unctional de!icits. In

children > ears o! a-e and older, 30 de-rees o! malrotation is acceptable, ith 10 de-rees o!an-ulation !or pro7imal !ractures and 1' de-rees !or more distal !ractures.> Complete

baonet apposition is acceptable, especiall !or distal radius !ractures, as lon- as an-ulationdoes not e7ceed 20 de-rees and 2 ears o! -roth remains.>

&omplications

It is important to note that children ith distal radius !ractures have particularl lo rates o!complications,3,'0 o!ten attainin- superior outcomes ith castin- alone. 4his results !romthe !act that the developin- bone in children has a remar/able abilit to remodel itsel! bac/into the correct anatomic orientation a!ter trauma, even an in*ur as severe as a !racture. Arecent stud shoed that onl 1@ out o! 30' distal radius !ractures in children had acomplication.'0 4he tendenc o! sur-eons to strive !or per!ect anatomic reduction in patientsith distal radius !ractures has caused debate over the appropriate treatment protocol !orchildren ith these in*uries. A stud b +o et al. compared the !unctional outcomes o!children ith distal radius !ractures ho underent closed reduction and those ho had onlsplint stabili:ation.'1 4he 3 children ho had no attempted reduction had the same!unctional results at their !olloup visits as the 3 children ho underent reduction. Inaddition, the !ound the total cost !or patients ith attempted reduction to be '0 more thanthose ithout reduction, even thou-h both -roups achieved the same !unctional outcomesith no complications at their !olloup visits. A more recent stud b AlAnsari et al.shoed that 0 out o! 12 children ith minimall an-ulated distal radius !ractures re8uiredsur-ical intervention or manipulation o! an tpe be!ore a cast as applied.30

En occasion, pediatric distal radius !ractures are accompanied b distal ulna !ractures. Moststudies to date have not separated outcomes !rom isolated distal radius !ractures !rom thosethat include a distal ulna !racture $complete or incomplete%.@ 6nostosis is a rare butdi!!icult to treat complication in this tpe o! in*ur. 4hose most at ris/ are individuals ithhi-h ener- trauma or those ith a concomitant head in*ur.'2 e!racture at the same site!olloin- a distal radius !racture is not in!re8uent i! the immobili:ation is removed too earland the child returns to activities be!ore the lamellar bone has !ull remodeled. Eutcomes!olloin- re!racture have been documented as havin- orse clinical outcomes than!ractures that have healed primaril.@,'3 6peci!icall !or -irls ith lo bone mass densit$DM+% and a previous distal !orearm !racture, the ris/ o! another distal radius !racture as

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shon to be times -reater than controls, since bone mineral deposition la-s behindincreases in bod ei-ht and bone len-th.'

-oung 'dult *utcomes

Ence patients have reached s/eletal maturit, most e7traarticular distal radius !ractureshave -ood lon-term !unctional results ith conservative treatment i! initiall reduced torestore anatomic hei-ht and inclination. In a 30ear !olloup stud o! oun- adults in6eden ith distal radius !ractures, the !ound that o! the 2# o! stud participants hohad e7traarticular !ractures $avera-e a-e o! 31 at time o! !racture, ran-e 1#&0%, onl 3@had even minor complaints o! pain, decreased mobilit, or cosmetic de!ormit.''

It is di!!icult to obtain satis!actor results ith intraarticular distal radius !ractures in oun-adults. 4his is due to the development o! smptomatic posttraumatic arthritis i! treated nonoperativel, ith rates reported as hi-h as 0.''&'@ In =nir/ and Kupiters 1>#( stud o!intraarticular !ractures in oun- adults $avera-e a-e at !racture o! 2# ears% treated eitherith cast immobili:ation or pins and plaster, the sa radio-raphic evidence o! arthritis in(' o! patients at @ ears !olloup. Ninetthree percent o! those ith radio-raphicarthritis ere smptomatic, hich the asserted ere most commonl the result o! amalreduced diepunch !ra-ment.'# Catalano et al studied 21 patients oun-er than the a-e o!

' ears ho had under-one internal !i7ation o! displaced intraarticular !ractures. At anavera-e o! @ ears, osteoarthrosis o! the radiocarpal *oint as radio-raphicall apparent in@( o! rists.'>

4he abilit o! oun- adults to return to or/ !olloin- a distal radius !racture ma be one o!the most ob*ective parameters b hich to assess the epidemiolo-ic impact o! these in*urieson this population. In =nir/s paper, onl one o! the 0 patients as unable to return to their

prior occupation due to the residual e!!ects o! their distal radius !racture.(0 In Catalanosstud, onl 1 o! 21 patients as unable to continue her current pro!ession as a nurse.'>

Althou-h rates o! posttraumatic arthritis ma be hi-h in these oun-er adults, data su--eststhat these reported smptoms ma not si-ni!icantl impact the livelihood o! these patients.

Elderly *utcomes

Ever the past decade, a multitude o! studies have attempted to discover and understand the!actors that de!ine treatment options and optimi:e outcomes in the active elderl patient!olloin- a distal radius !racture. Hoever, these !actors are o!ten interconnected anddi!!icult to isolate !or evaluation !rom an epidemiolo-ic perspective. Ene o! the ma*orlimitin- !actors in e7aminin- these outcomes is that !e studies desi-nate hether the!racture has intraarticular e7tension. 4his seems to be emer-in- as an important !actor !orre-ainin- !unctional motion and stren-th, rather than absolute measures o! !ractureali-nment and malunion.

Mortality and Functional Decline

+istal radius !ractures can be a si-ni!icant source o! mortalit and loss o! independence inthe elderl. In e7aminin- the !unctional status o! a prospective cohort o! >,000 older omen

!olloed throu-h the 6tud !or Esteoporotic ractures, omen ith a rist !racture ere'0 more li/el than those ithout !ractures to have a clinicall important !unctionaldecline. 4his decline as practicall de!ined b orsenin- abilit to prepare meals, per!orm

heav house/eepin-, climb 10 stairs, -o shoppin-, and -et out o! a car.(0 Mortalit rates-athered !rom the Center !or +isease Control and the National +eath Inde7 in patients itha distal radius !racture, compared to a standard 56 matched control -roup, ere shon to besi-ni!icantl hi-her than those o! the standard 56 elderl population, an avera-e o! a 1

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increase @ ears a!ter the !racture.(1 In this stud, men ith a distal radius !racture ere!ound to be 2.(' times more li/el to die in this time period than omen ith this !racture,li/el due in part b the lar-est increase in incidence in men occurrin- in the over#0 earold a-e -roup. In practice, this in!ormation can be used to provide insi-ht to the patient and!amil that a distal radius !racture in an elderl man portends orse outcomes than the same!racture in a oman.

'ge

Previous radio-raphic parameters !or acceptable reductions in displaced distal radius!ractures had been developed usin- a subset o! oun-er, more active patients. In Karme/o etals stud in 200@, the asserted that these !actors had not been appropriatel validated !orthe Gelderl in their stud $avera-e a-e o! (#.'% and had little e!!ect on sel!reported!unctional outcomes in shortterm !olloup in nonoperative cases.(2 In a retrospectivestud o! 11 patients $avera-e a-e o! @>% ho met operative criteria !or unstable distalradius !racture, but !or hom (3 declined sur-er, Mattila !ound no si-ni!icant di!!erencesat ' ears in !unctional outcomes or pain.(3 A recent metaanalsis o! more than 1,000 distalradius !ractures comparin- cast immobili:ation to an operative treatment in patients olderthan (0 has shon that despite orse radio-raphic outcomes associated ith castin-,!unctional outcomes ere no di!!erent !rom those o! sur-icall treated -roups.

)ncreasing Rates of *perati!e )nter!entions

Ever the past 10 ears, there has been an increase in the use o! sur-ical interventions !or thetreatment o! distal radius !ractures.(3,( Althou-h this mi-ht appear to be directl correlatedith the increased incidence o! these !ractures seen in recent ears, no evidence is availableto support such a claim. Matilla et al !ound that beteen 1>># and 200#, the use o! sur-icalintervention !or the treatment o! distal radius !ractures doubled.(3 4he also !ound anincrease in the use o! internal !i7ation over other techni8ues, hich more than doubled overthe 11 ear period o! the stud.

A recent tenear revie o! Medicare data conducted b Chun- et al. documented trends inthe treatment o! distal radius !ractures in the elderl.( 4he !ound that closed !i7ation asthe most prevalent !orm o! !racture !i7ation, but the use o! this treatment protocol has

decreased !rom #2 to @0 over the past ten ears. It as also documented that distalradius !ractures are increasin-l bein- treated b hand sur-eons, ith rates increasin- !rom .# to 3.> durin- the stud period. Additionall, hand sur-eons ere shon to be moreli/el to use internal !i7ation in the treatment o! these !ractures. In contrast, orthopaedicsur-eons ere !ound to be '.@ times more li/el than hand sur-eons to use closed treatment.4his coincides ith a stud b =oval et al. shoin- hand sur-eons leanin- toards the useo! internal !i7ation over closed treatment.(' 4here is evidence that over '0 o! !racturestreated ith closed reduction are pla-ued b malunion, hich hi-hli-hts the importance thatdistal radius !ractures should be evaluated on a case b case basis.((,(@

4he increased tendenc !or sur-ical manipulation in recent ears has been coupled ith ashi!t in !avor o! open reduction and internal !i7ation over other treatment options. Althou-hthis ne treatment is e7citin-, no conclusive evidence has shon it to be more e!!ective than

an other treatment protocol. It is not clear h this increase is occurrin-, but it ma bebecause more distal radius !ractures are bein- treated b hand sur-eons. It also ma be theresult o! increasin-l success!ul mar/etin- schemes directed toards sur-eons, or even *ustthe e7citement that comes ith the novelt o! a ne technolo-. 9hatever the case,numerous studies have made it clear that there is no si-ni!icant di!!erence beteen the lon-term !unctional outcomes o! EI and other therapeutic options !or these !ractures.(#&@1

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Althou-h some o! these studies !ound that the volar loc/in- plate did provide better shortterm outcomes, the lon- term results remained the same.

6ee/in- to anser some o! these di!!icult sur-ical treatment 8uestions in the elderl, the9I64 $9rist and adius In*ur 6ur-ical 4rial% stud -roup as !ormed in 200>,comprised o! 1> centers across North America ith participation !rom both plastic andorthopaedic hand sur-eons.@2 4he -roup collaborated on the stud desi-n and pilot trials,

and obtained NIH !undin- to investi-ate the outcomes o! volar loc/in- plates compared toother !orms o! sur-ical !i7ation throu-h a multicenter clinical trial $MCC4%. 4his MCC4desi-n obtained throu-h consensus structures a ri-orous stud protocol, collects a diverse

patient sample, and recruits a lar-e number o! patients to detect smaller treatment e!!ects.

A +artmouth stud o! over 100,000 Medicare patients beteen 1>># and 200 shoedinternal !i7ation rates close to doublin- !rom ' to # nationall across all a-es. Moreinterestin-l, the tpe o! operative !i7ation as e7tremel variable beteen hospital re!erralre-ions, ith internal !i7ation ran-in- !rom . to 2' in some areas.@3 4hese ma*ordi!!erences in treatment rates are not une7pected -iven the variabilit in !racture patterns atthe distal radius, numerous treatment options available, and the lac/ o! consensus in theliterature re-ardin- treatment outcomes.

4he most recent article to e7plore the use o! internal !i7ation !or distal radius !ractures in theMedicare population e7amined re-ional variations, ethnic variabilit and treatin- phsiciancharacteristics to better understand the !actors contributin- to the chan-in- trends.@ In200@, the !ound nearl #(,000 Medicare patients su!!ered a closed distal radius !racture, o!hich 1@ e treated ith internal !i7ation. 4his is over to times the rate o! internal!i7ation !rom a ( ear time period endin- *ust 3 ears prior to the stud. 4he also !oundmen ere si-ni!icantl less li/el to receive internal !i7ation than omen, as ere blac/scompared to hites. Bi/e the +artmouth stud, the also sa nearl a 10!old di!!erence inthe rates o! internal !i7ation across di!!erent hospital re!erral re-ions. 4he stud thene7amined these di!!erences b re-ion based on hether the patient as treated b a handsur-eon, !indin- si-ni!icant positive correlations ith the rates o! internal !i7ation to the

percenta-e o! patients treated b a hand sur-eon in each area.

*steoporosis Treatment and Ris# of Future Fracture+istal radius !ractures in the active elderl population can be one o! the !irst indicators o!underlin- osteoporosis, and the event represents a prime point !or intervention. In the ear!olloin- a distal radius !racture, studies have shon ' and10 times -reater rates o!vertebral !ractures in omen and men respectivel, in accordance ith a (0 increase in therates o! hip !ractures !or omen over @0.@' It can be ar-ued that the easiest distal radius!racture to treat is the one that does not happen, and a number o! !alls prevention initiativesin the active elderl have been both success!ul and coste!!ective in preventin- distal radius!ractures.@(,@@ Ether simple preventative measures include arnin-s !or dan-erous eatherconditions and clearin- or preventin- accumulation o! sno and ice in order to decrease theincidence o! !alls resultin- in this in*ur.3(

4he elderl population has several options to aid in the prevention o! distal radius !ractures.

Ene o! the most important preventative measures includes the proper dia-nosis andtreatment o! bone diseases such as osteoporosis and osteopenia. Hoever, in a stud o! 111

patients in the militar medical sstem to determine rates o! osteoporosis !ollo up in theear !olloin- a distal radius !racture, it as discovered that onl (( received some sort o!intervention !or osteoporosis. Ene 8uarter o! the patients ere re!erred to endocrinolo-,20 had a +

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4he use o! bisphosphonates in combination ith supplements such as Calcium and itamin+ has been shon to help decrease the ris/ o! !ractures due to osteopenia and osteoporosis.Disphosphonates $DPs% are the most common therap protocol !or the treatment o! boneresorption due to the e!!ects o! osteoporosis and other bone diseases.@>' Esteoporosis is aleadin- ris/ !actor !or distal radius !ractures, and the use o! DPs has plaed an important rolein reducin- this ris/. esearch is currentl providin- ne insi-hts into the e7act mechanismo! action that -ives DPs their antiresorptive properties.#(

Disphosphonates are able to increase bone mineral calcium throu-h the inhibition o!osteoclastic bone resorption b alterin- upstream di!!erentiation o! osteoctes in addition to

promotin- the apoptosis o! these osteoclasts.#@ +ue to the suppressive actions the have onbone remodelin-, it as ori-inall theori:ed that DPs ould disrupt the healin- process o!!ractures. It has been shon that this is not the case, and in !act DPs stimulate boneremodelin- b promotin- the recruitment and activit o! osteoblasts and osteoctes, hiledecreasin- apoptosis o! these cells.## 4his activit causes an increase in bone mineraldensit, hich can result in up to a '0 decrease in the ris/ o! !uture !ractures.#> A recentstud !ound less than a one ee/ di!!erence in the rate o! distal radius !racture healin- !orthose ta/in- DPs and those not ta/in- them $'' das versus > das%, a di!!erence !elt to benot clinicall si-ni!icant>0

ecent reports have hi-hli-hted that bisphosphonate treatment is not ithout ris/, despite anestimated 30 million individuals prescribed bisphosphonate therap per ear in the 56alone.>1 =non esopha-eal irritation is common, but atpical subtrochanteric !emur!ractures are increasin-l bein- reported, primaril in the settin- o! lon-term

bisphosphonate use.>2&> Esteonecrosis o! the *a has also been reported to occur in up to .0 o! osteoporotic patients on bisphosphonate therap.>' 4he dose dependenc e!!ect isno more clearl de!ined, but the e7act patho-enic role o! bisphosphonates in these atpical

bone events remains unclear. 4he phsician must ei-h the ris/s and bene!its ith thepatient, but the absolute ris/ o! atpical !racture associated ith bisphosphonate usecompared ith the hi-h ris/ o! osteoporotic !ractures is small, hen compared to the

bene!icial e!!ects o! the dru-.

4he abilit to e!!icientl and accuratel dia-nose osteoporosis is another important step that

could help decrease medical costs and patient morbidit o! those a!!licted b this disease. Itould not be cost e!!ective to dia-nose and treat everone, so it is essential that onl thoseat hi-h ris/ !or osteoporosis should be evaluated and treated.

&onclusion

Possessin- a /noled-e o! the incidence and outcomes o! distal radius !ractures allos thephsician to better counsel individual patients and determine the best mana-ement tooptimi:e treatment. Althou-h treatment outcomes !or pediatric and oun- adults are !airlell de!ined !or distal radius !ractures, recent research in the elderl population has madedecisionma/in- !or the patient and sur-eon more comple7. It is becomin- increasin-ldi!!icult to de!ine the di!!erence beteen the active Golder adult that ill continue to placehi-h demands on an in*ured rist, and the true Gelderl that ma better adapt to an

imper!ect outcome. Bar-e multicenter studies, such as the 9I64 stud, ith lon-term!olloup ma be the onl a to accuratel delineate the best treatment options !or anindividual based on outcomes !or a similar patient population.

'c#no"ledgments

6upported in part b -rants !rom the National Institute on A-in- and National Institute o! Arthritis andMusculos/eletal and 6/in +iseases $01 A0(20((% and !rom the National Institute o! Arthritis and

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Musculos/eletal and 6/in +iseases $201 A0@32#0(% and a Midcareer Investi-ator Aard in PatientErientedesearch $=2 A0'3120% $to +r. =evin C. Chun-%.

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Figure 1.

4he increasin- incidence o! distal radius !ractures in bos and -irls under the a-e o! 20. 4herise in incidence as statisticall si-ni!icant !or both bos and -irls.+ata !rom =hosla et al., Incidence o! Childhood +istal orearm ractures Ever 30 Qears.e!. 20

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Figure 2.

A stron- increase in the incidence o! sports related !ractures as !ound in the pediatricpopulation, hich ma account !or the rise in the overall incidence rates o! distal radius!ractures.+ata !rom Putter et al., 4rends in 9rist ractures in Children and Adolescents, 1>>@&200>.e!. 3

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Figure 3.

4his shos the combined pea/ rate o! !ractures o! both bos and -irls to be around 10 earsold, correspondin- to pea/ rates documented in other studies.+ata !rom Chun- and 6pilson, 4he re8uenc and

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Figure 4.

Incidence rate o! distal radius !ractures per 10,000 people in men and omen a-ed 1> to #0.4he increasin- incidence as statisticall si-ni!icant hen comparin- the three a-e -roupsin both men and omen.+ata !rom Dro-ren et al., Incidence and Characteristics o! +istal adius ractures in a

6outhern 6edish e-ion. e!. 32

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Figure 5.

Incidence rate o! distal radius !ractures per 100,000 people in men and omen a-ed 1( to#0. A statisticall si-ni!icant di!!erence as documented beteen the overall incidence o!men and omen, ith omen havin- a hi-her rate o! !racture.+ata !rom lin//ila et al.,