Evaluation and treatment of osetoporotic distal radius fracture in the elderly patient

  • Eric M. Padegimas
  • Daniel A. OseiEmail author
Hand and Wrist (DA Osei, Section editor)


Distal radius fractures are an increasingly prevalent upper extremity injury, especially among elderly patients. While treatment guidelines for the acute bony injury have been well documented, treatment of the underlying metabolic bone disease has been less commonly discussed in the orthopedic literature. Distal radius fractures in the elderly patient should be considered a sentinel event for injuries associated with greater morbidity and mortality, such as hip fracture. Management of fracture-related factors, such as osteoporosis and increased fall risk following a distal radius fracture, may prevent the mortality and morbidity of future injuries. This review highlights both the fracture-specific and medical goals of treatment in the elderly patient with a distal radius fracture.


Distal radius fracture Osteoporosis Wrist Geriatric Vitamin D Review 



No potential conflicts of interest relevant to this article were reported.


Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  1. 1.
    Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26:908–15.PubMedCrossRefGoogle Scholar
  2. 2.
    •• Nellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand Clin. 2012;28(2):113–25. Epub 2012 Apr 14. This study showed that epidemiological data over the past 40 years have shown an overall increase in prevalence of DRFs, especially in the elderly and pediatric populations.PubMedCrossRefGoogle Scholar
  3. 3.
    Melton III L, Amadio P, Crowson C, et al. Long-term trends in the incidence of distal forearm fractures. Osteoporos Int. 1998;8:341–8.PubMedCrossRefGoogle Scholar
  4. 4.
    •• de Putter CE, van Beeck EF, Looman CW, et al. Trends in wrist fractures in children and adolescents, 1997-2009. J Hand Surg Am. 2011;36:1810–5.e2. This study showed an increase in the incidence of sports-related DRFs in the pediatric population.PubMedCrossRefGoogle Scholar
  5. 5.
    Hagino H, Yamamoto K, Ohshiro H, et al. Changing incidence of hip, distal radius, and proximal humerus fractures in Tottori Prefecture, Japan. Bone. 1999;24:265–70.PubMedCrossRefGoogle Scholar
  6. 6.
    Thompson PW, Taylor J, Dawson A. The annual incidence and seasonal variation of fractures of the distal radius in men and women over 25 years in Dorset, UK. Injury. 2004;35:462–6.PubMedCrossRefGoogle Scholar
  7. 7.
    Brenner H, Arndt V. Epidemiology in aging research. Exp Gerontol. 2004;39:679–86.PubMedCrossRefGoogle Scholar
  8. 8.
    Baron JA, Karagas M, Barrett J, et al. Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. Epidemiology. 1996;7:612–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Schoenborn CA. Health habits of U.S. adults 1985: the “Almeda 7” revisited. Public Health Rep. 1985;101:571–80.Google Scholar
  10. 10.
    Rowe JW, Kahn RL. Successful aging. New York: Pantheon Books; 1998.Google Scholar
  11. 11.
    Ring D, Jupiter JB. Treatment of osteoporotic distal radius fractures. Osteoporos Int. 2005;16 Suppl 2:S80–4. Epub 2004 Dec 22.PubMedCrossRefGoogle Scholar
  12. 12.
    •• Flinkkila T, Sirnio K, Hippi M, et al. Epidemiology and seasonal variation of distal radius fractures in Oulu, Finland. Osteoporos Int. 2011;22:2307–12. This study showed that the incidence of DRFs in elderly women in Finland is significantly higher during the winter months. Concurrent weather analysis from the Finnish Meteorological Institute suggests that slipperiness of the pavement could explain the increased winter risk.PubMedCrossRefGoogle Scholar
  13. 13.
    Cummings SR, Black DM, Rubin SM. Lifetime risks of hip, Colles’, or vertebral fracture and coronary heart disease among white postmenopausal women. Arch Intern Med. 1989;149:2445–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Singer BR, McLauchlan GJ, Robinson CM, Christie J. Epidemiology of fractures in 15,000 adults: the influence of age and gender. J Bone Joint Surg. 1998;80B:243–8.CrossRefGoogle Scholar
  15. 15.
    Kanterewicz E, Yanez A, Perez-Pons A, et al. Association between Colles’ fracture and low bone mass: age-based differences in postmenopausal women. Osteoporos Int. 2002;13:824–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Lofman O, Hallberg I, Berglund K, et al. Women with low-energy fracture should be investigated for osteoporosis. Acta Orthop. 2007;78:813–21.PubMedCrossRefGoogle Scholar
  17. 17.
    •• Oyen J, Rohde GE, Hochberg M, et al. Low-energy distal radius fractures in middle-aged and elderly women-seasonal variations, prevalence of osteoporosis, and associates with fractures. Osteoporos Int. 2010;21:1247–55. This study showed that patients who have suffered a DRF who are older than 50 years should be evaluated by bone densitometry because of the increased prevalence of osteoporosis in this population.PubMedCrossRefGoogle Scholar
  18. 18.
    •• Oyen J, Brudvik C, Gjesdal CG, et al. Osteoporosis as a risk factor for distal radial fractures: a case-control study. J Bone Joint Surg Am. 2011;93:348–56. This study showed that patients who have suffered a DRF who are older than 50 years should be evaluated by bone densitometry because of the increased prevalence of osteoporosis in this population.PubMedCrossRefGoogle Scholar
  19. 19.
    •• Oyen J, Rohde G, Hochberg M, et al. Low bone mineral density is a significant risk factor for low-energy distal radius fractures in middle-aged and elderly men: a case-control study. BMC Musculoskelet Disord. 2011;12:67. This study suggests that since low bone mineral density is a risk factor for low-energy DRF in men older than 50 years, improvement of bone mineral density by both pharmacological and nonpharmacological means may decrease incidence.PubMedCrossRefGoogle Scholar
  20. 20.
    •• Melton 3rd LJ, Christen D, Riggs BL, et al. Assessing forearm fracture risk in postmenopausal women. Osteoporos Int. 2010;21:1161–9. This study shows that in postmenopausal women, femoral neck bone mineral densitometry is an adequate test for routine clinical risk assessment of DRF.PubMedCrossRefGoogle Scholar
  21. 21.
    Clayton RA, Gaston MS, Ralston SH, et al. Association between decreased bone mineral density and severity of distal radial fractures. J Bone Joint Surg Am. 2009;91:613–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357:266–81.PubMedCrossRefGoogle Scholar
  23. 23.
    Bahlous A, Farjallah N, Bouzid K, et al. Hypovitaminosis D in Tunisian osteoporotic postmenopausal women and the relationship with bone fractures. Tunis Med. 2009;87:188–90.PubMedGoogle Scholar
  24. 24.
    Bakhtiyarova S, Lesnyak O, Kyznesova N, et al. Vitamin D status among patients with hip fracture and elderly control subjects in Yekaterinburg, Russia. Osteoporos Int. 2006;17:441–6.PubMedCrossRefGoogle Scholar
  25. 25.
    Wright S, Beringer T, Taggart H, Keegan D, Kelly J, Whithead E, et al. A study of male patients with forearm fracture in Northern Ireland. Clin Rheumatol. 2007;26:191–5.PubMedCrossRefGoogle Scholar
  26. 26.
    •• Jang WY, Chung MS, Baek GH, Song CH, Cho HE, Gong HS. Vitamin D levels in post-menopausal Korean women with a distal radius fracture. Injury. 2012;43(2):237–41. Epub 2011 Nov 14. This study shows that postmenopausal women with DRFs had significantly lower vitamin D levels than the control group.PubMedCrossRefGoogle Scholar
  27. 27.
    •• Oyen J, Apalset EM, Gjesdal CG, Brudvik C, Lie SA, Hove LM. Vitamin D inadequacy is associated with low-energy distal radius fractures: a case–control study. Bone. 2011;48:1140–5. This study shows an association between vitamin D inadequacy and low-energy DRFs. The differences in vitamin D levels are independent of bone mineral densitometry, body mass index, or smoking history.PubMedCrossRefGoogle Scholar
  28. 28.
    Owen RA, Melton 3rd LJ, Ilstrup DM, Johnson KA, Riggs BL. Colles’ fracture and subsequent hip fracture risk. Clin Orthop Relat Res. 1982:37–43.Google Scholar
  29. 29.
    Mallmin H, Ljunghall S, Persson I, Naessen T, Krusemo UB, Bergstrom R. Fracture of the distal forearm as a forecaster of subsequent hip fracture: a population-based cohort study with 24 years of follow-up. Calcif Tissue Int. 1993;52:269–72.PubMedCrossRefGoogle Scholar
  30. 30.
    Lauritzen JB, Schwarz P, McNair P, Lund B, Transbøl I. Radial and humeral fractures as predictors of subsequent hip, radial or humeral fractures in women, and their seasonal variation. Osteoporos Int. 1993;3(3):133–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Haentjens P, Autier P, Collins J, Velkeniers B, Vanderschueren D, Boonen S. Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women. A meta-analysis. J Bone Joint Surg Am. 2003;85-A(10):1936–43.PubMedGoogle Scholar
  32. 32.
    Young BT, Rayan GM. Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years. J Hand Surg Am. 2000;25(1):19–28.PubMedCrossRefGoogle Scholar
  33. 33.
    U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. preventive services task force recommendation statement. Ann Intern Med. 2011;154(5):356–64. Epub 2011 Jan 17.Google Scholar
  34. 34.
    Nelson HD, Haney EM, Dana T, Bougatsos C, Chou R. Screening for osteoporosis: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153(2):99–111.PubMedGoogle Scholar
  35. 35.
    Jackson RD, LaCroix AZ, et al. Calcium plus vitamin D supplementation and the risk of fractures. N Engl J Med. 2006;354(7):669–83.PubMedCrossRefGoogle Scholar
  36. 36.
    •• Kuehn BM. USPSTF: Taking vitamin D and calcium doesn't prevent fractures in older women. JAMA. 2012;308(3):225–6. This study showed no statistically significant decrease in fracture incidence with low-dose vitamin D and calcium supplementation in otherwise healthy women between the ages of 50 and 79 years.PubMedCrossRefGoogle Scholar
  37. 37.
    Vieth R, Chan PC, MacFarlane GD. Efficacy and safety of vitamin D3 intake exceeding the lowest observed adverse effect level. Am J Clin Nutr. 2001;73:288–94.PubMedGoogle Scholar
  38. 38.
    Aloia JF, Patel M, Dimaano R, et al. Vitamin D intake to attain a desired serum 25-hydroxyvitamin D concentration. Am J Clin Nutr. 2008;87:1952–8.PubMedGoogle Scholar
  39. 39.
    •• Clemson L, Fiatarone Singh MA, Bundy A, Cumming RG, Manollaras K, O'Loughlin P, Black D. Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial. BMJ. 2012;345:e4547. This study shows that a functional-based exercise program integrated into activities of daily living is more effective at reducing falls in the elderly than are traditional exercise regimens.PubMedCrossRefGoogle Scholar
  40. 40.
    Synn AJ, Makhni EC, Makhni MC, Rozental TD, Day CS. Distal radius fractures in older patients: is anatomic reduction necessary? Clin Orthop Relat Res. 2009;467(6):1612–20. Epub 2008 Dec 12.PubMedCrossRefGoogle Scholar
  41. 41.
    Abbaszadegan H, Jonsson U. External fixation or plaster cast for severely displaced Colles’ fractures? Prospective 1-year study of 46 patients. Acta Orthop Scand. 1990;61:528–30.PubMedCrossRefGoogle Scholar
  42. 42.
    Fitoussi F, Ip WY, Chow SP. Treatment of displaced intraarticular fractures of the distal end of the radius with plates. J Bone Joint Surg Am. 1997;79:1303–12.PubMedGoogle Scholar
  43. 43.
    Howard PW, Stewart HD, Hind RE, Burke FD. External fixation or plaster for severely displaced comminuted Colles’ fractures? A prospective study of anatomical and functional results. J Bone Joint Surg Br. 1989;71:68–73.PubMedGoogle Scholar
  44. 44.
    Jenkins NH, Jones DG, Mintowt-Czyz WJ. External fixation and recovery of function following fractures of the distal radius in young adults. Injury. 1988;19:235–8.PubMedCrossRefGoogle Scholar
  45. 45.
    Kapoor H, Agarwal A, Dhaon BK. Displaced intra-articular fractures of distal radius: a comparative evaluation of results following closed reduction, external fixation and open reductionbwith internal fixation. Injury. 2000;31:75–9.PubMedCrossRefGoogle Scholar
  46. 46.
    Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 1986;68:647–59.PubMedGoogle Scholar
  47. 47.
    Knox J, Ambrose H, McCallister W, Trumble T. Percutaneous pins versus volar plates for unstable distal radius fractures: a biomechanic study using a cadaver model. J Hand Surg Am. 2007;32:813–7.PubMedCrossRefGoogle Scholar
  48. 48.
    Leung F, Tu YK, Chew WY, Chow SP. Comparison of external and percutaneous pin fixation with plate fixation for intra-articular distal radius fractures. J Bone Joint Surg Am. 2008;90:16–22.PubMedCrossRefGoogle Scholar
  49. 49.
    Merchan EC, Breton AF, Galindo E, Peinado JF, Beltran J. Plaster cast versus Clyburn external fixation for fractures of the distal radius in patients under 45 years of age. Orthop Rev. 1992;21:1203–9.PubMedGoogle Scholar
  50. 50.
    Pring DJ, Barber L, Williams DJ. Bipolar fixation of fractures of the distal end of the radius: a comparative study. Injury. 1988;19:145–8.PubMedCrossRefGoogle Scholar
  51. 51.
    Stein H, Volpin G, Horesh Z, Hoerer D. Cast or external fixation for fracture of the distal radius: a prospective study of 126 cases. Acta Orthop Scand. 1990;61:453–6.PubMedCrossRefGoogle Scholar
  52. 52.
    Beharrie AW, Beredjiklian PK, Bozentka DJ. Functional outcomes after open reduction and internal fixation for treatment of displaced distal radius fractures in patients over 60 years of age. J Orthop Trauma. 2004;18(10):680–6.PubMedCrossRefGoogle Scholar
  53. 53.
    Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg Am. 2009;91(8):1868–73.PubMedCrossRefGoogle Scholar
  54. 54.
    •• Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am. 2011;36(5):824–35.e2. This study shows that in DRF patients older than 60 years, there was no statistically significant difference in functional outcome after treatment with cast immobilization or surgical intervention.PubMedCrossRefGoogle Scholar
  55. 55.
    Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am. 2006;88(9):1944–51.PubMedCrossRefGoogle Scholar
  56. 56.
    Arora R, Gabl M, Gschwentner M, Deml C, Krappinger D, Lutz M. A comparative study of clinical and radiologic outcomes of unstable colles type distal radius fractures in patients older than 70 years: nonoperative treatment versus volar locking plating. J Orthop Trauma. 2009;23(4):237–42.PubMedCrossRefGoogle Scholar
  57. 57.
    Anzarut A, Johnson JA, Rowe BH, Lambert RG, Blitz S, Majumdar SR. Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures. J Hand Surg Am. 2004;29(6):1121–7.PubMedCrossRefGoogle Scholar
  58. 58.
    •• Chung KC, Shauver MJ, Yin H, Kim HM, Baser O, Birkmeyer JD. Variations in the use of internal fixation for distal radial fracture in the United States medicare population. J Bone Joint Surg Am. 2011;93(23):2154–62. This study shows that the use of internal fixation for DRFs differs widely on the basis of geography and patient demographics.PubMedCrossRefGoogle Scholar
  59. 59.
    Singer BR, McLauchlan GJ, Robinson CM, Christie J. Epidemiology of fractures in 15,000 adults: the influence of age and gender. J Bone Joint Surg Br. 1998;80:243–8.PubMedCrossRefGoogle Scholar
  60. 60.
    Thomas E, Wilkie R, Peat G, Hill S, Dziedzic K, Croft P. The North Staffordshire Osteoarthritis Project–NorStOP: prospective, 3-year study of the epidemiology and management of clinical osteoarthritis in a general population of older adults. BMC Musculoskelet Disord. 2004;5:2.PubMedCrossRefGoogle Scholar
  61. 61.
    Rozental TD, Makhni EC, Day CS, Bouxsein ML. Improving evaluation and treatment for osteoporosis following distal radial fractures. A prospective randomized intervention. J Bone Joint Surg Am. 2008;90(5):953–61.PubMedCrossRefGoogle Scholar
  62. 62.
    •• Bischoff-Ferrari HA, Willett WC, Orav EJ, Lips P, Meunier PJ, Lyons RA, Flicker L, Wark J, Jackson RD, Cauley JA, Meyer HE, Pfeifer M, Sanders KM, Stähelin HB, Theiler R, Dawson-Hughes B. A pooled analysis of vitamin D dose requirements for fracture prevention. N Engl J Med. 2012;367(1):40–9. This study shows that high-dose vitamin D supplementation ( > 800 IU daily) was favorable in prevention of hip fracture and any nonvertebral fracture in people who were 65 years or older.PubMedCrossRefGoogle Scholar
  63. 63.
    •• Shauver MJ, Clapham PJ, Chung KC. An economic analysis of outcomes and complications of treating distal radius fractures in the elderly. J Hand Surg Am. 2011;36(12):1912–8.e1-3. This study shows that Medicare patients show little economic preference between different treatment modalities for DRFs.PubMedCrossRefGoogle Scholar
  64. 64.
    Ray NF, Chan JK, Thamer M, Melton LJ. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation. J Bone Miner Res. 1997;12:24–35.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of Orthopedic SurgeryWashington University School of MedicineSt. LouisUSA

Personalised recommendations