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Hand 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.

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The Epidemiology of Distal Radius Fractures

Kate W. Nellans, MD, MP 1, E!an Ko"als#i, $%2, and Ke!in &. &hung, MD, M%3 1 Hand Fellow, University o Michi!an Health "yste#, "ection o Plastic "ur!ery
2

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

3

Pro essor o "ur!ery, "ection o Plastic "ur!ery, Assistant %ean A airs, &he University o Michi!an Medical "chool

or Faculty

'(stract
+istal radius !ractures are one o! the most common t pes 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 0ell1bein- o! oun- adults. +ata !rom the past 20 ears has documented a trend to0ards an overall increase in the prevalence o! this in*ur . 3or the pediatric population, this increase can li/el be attributed to a sur-e in sports related activities. 4he -ro0th o! the elderl population and a rise in the number o! active elderl are directl responsible !or the increase seen in this a-e -roup. 5nderstandin- the epidemiolo- o! this !racture is an important step to0ards the improvement o! the treatment strate-ies and preventative measures 0hich 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 t pes o! !ractures, 0ith over (20,000 cases reported durin- 2001 in the 56 alone.1 3or reasons not !ull understood, and li/el multi1!actorial, the incidence o! this !racture appears to be on the rise in the 56 and abroad.2&' Man o! the societal e!!ects o! these !ractures e7tend be ond the si-ni!icant medical costs, includin- decreased school attendance, lost 0or/ hours, loss o! independence and lastin- disabilit . 3ra-mented care and codin- discrepancies can ma/e accountin- !or the true number o! these !ractures di!!icult, li/el underestimatin- the rates t picall 8uoted in the literature. 9hen anal :in- the incidence o! distal radius !ractures, there are three ma*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 the contributin- !actors 0ill be e7amined in this paper. In addition to the 3 main a-e -roups,

; 2012 <lsevier Inc. All ri-hts reserved. Correspondin- Author" =evin C. Chun-, M+, M6, 6ection o! Plastic 6ur-er , 5niversit o! Michi-an Health 6 stem, 2130 4aubman Center, 6PC '320, 1'00 <. Medical Center +rive, Ann Arbor, MI, 2#10>1'320, /ecchun-?umich.edu, Phone @321>3(1'##', 3a7 @321@(31'3'2. Publisher's Disclaimer: 4his is a P+3 !ile o! an unedited manuscript that has been accepted !or publication. As a service to our customers 0e are providin- this earl version o! the manuscript. 4he manuscript 0ill under-o cop editin-, t pesettin-, and revie0 o! the resultin- proo! be!ore it is published in its !inal citable !orm. Please note that durin- the production process errors ma be discovered 0hich could a!!ect the content, and all le-al disclaimers that appl to the *ournal pertain.

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-ender and ethnicit ma also be considered distinct ris/ !actors 0ithin each o! these populations. 5nderstandin- the epidemiolo- o! distal radius !ractures can help ph sicians choose the most appropriate treatment options !or the !racture, as 0ell as e!!ectivel tar-et preventative measures to0ards at1ris/ populations.

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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 0ere due to hand and 0rist !ractures. Aadius and ulna !ractures consisted o! 22. o! these !ractures. 1 4his stud corresponds to a stud b Barsen and Bauritsen sho0in- that distal radius !ractures accounted !or 2.'. o! all emer-enc department visits.( 4hese numbers var more 0idel in earlier reports, but still represent a hi-h incidence rate. In 1>(2, an anal sis o! !ractures in 60eden documented the number o! distal radius and ulna !ractures to be as hi-h @'. o! all !orearm !ractures.@ A stud b =no0elden et al. in 1>(2 !ound 32. o! all !ractures seen in 0omen 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 the pediatric, adult, and elderl populations in recent ears. 4his phenomenon has been a sub*ect o! debate as earl as the 1>(0Cs 0hen Al!!ram and Dauer published their report on the increasin- occurrence o! distal radius !ractures in a lar-e 60edish cit .@ A stud !rom Aochester, Minnesota !ound a 1@. increase in the incidence o! this in*ur over a 20 ear period.2 4he incidence in 60eden almost doubled !or the elderl population over a 30 ear time span 0hen 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 remained the same, lendin- !urther validit to the increase in distal radius !ractures as a le-itimate trend.> Althou-h there is no sin-le !actor responsible !or this phenomenon due to the absolute prevalence o! distal radius !ractures, an individual contributin- !actor is bound to have con!oundin- variables. Man theories have been proposed to determine the source o! the increasin- rates o! distal radius !ractures, but studies correlatin- a speci!ic cause to the incidence o! this in*ur must be care!ull evaluated. 4he in!luence o! li!est le and environmental !actors on the ris/ and incidence 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 in urban 0omen over rural 0omen.10 Althou-h the data indicated a si-ni!icant di!!erence bet0een ris/ !actors, it could not seem to determine the cause o! this discrepanc , even a!ter anal :in- li!est le and health !actors. Ethers point to the impact o! epi-enetic in!luences on the development o! diseases such as childhood obesit and osteoporosis as a basis !or the increasin- incidence o! this !racture in di!!erent populations.11,12 It is possible that chan-incultural 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 remain active, !ractures due to relativel minor traumas have increased. @ Ether theories 0ill be discussed in !urther detail throu-hout the !ollo0in- sections. &os ts

As the incidence o! distal radius !ractures rises, the short and lon- term costs become apparent. <ach ear, !ractures account !or over hal! o! the da s patients spend in the hospital receivin- treatment and care !or upper e7tremit in*uries.1,13 4he costs o! treatin- distal radius !ractures in the pediatric population o! the 5nited 6tates has been cited to be in
Hand Clin. Author manuscript; available in PMC 2013 Ma 01.

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up0ards 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 0ith respect to the elderl communit . 4he !ound in 200@, Medicare paid F1@0 million in distal radius !racture related pa ments.12 Additionall , the pro*ected that the !uture burden o! Medicare could be F220 million i! the current trend in the use o! internal !i7ation continues. 4hese costs did not include an secondar e7penses associated 0ith this in*ur such as prescription dru-s, lost time at 0or/, and loss o! independence, 0hich ma be more si-ni!icant than the direct costs. 4his data reveals the si-ni!icant socioeconomic costs incurred as a direct result o! distal radius !ractures, and hi-hli-hts the importance o! anal :in- preventative measures and treatment protocols !or individuals 0ho are at a hi-h ris/ !or or su!!er !rom this in*ur .

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Pediatric )ncidence
Children and adolescents are at a particularl hi-h ris/ !or distal radius !ractures, in part due to 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 estimated that until the a-e o! 1(, the ris/ o! -ettin- a !racture is 22. in bo s and 2@. in -irls.1' In this anal sis, !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 in terms o! medical costs, lost time !rom school, and even !uture 0or/ potential. )ncreasing o!erall incidence 4he incidence o! distal radius !ractures in children appears to be risin-, but it is di!!icult to e7plain the e7act cause o! this stead increase over the past 20 ears $3i-ure 1%. 3,1>,20 6ome studies su--est this could be the result o! an overall increase in the participation o! sports related activities in the pediatric population.3,12,1>,21 Putter et al !ound an increase in sports related activities correlated 0ith an increase in sports1related distal radius !ractures $3i-ure 2%. In another stud , 23. o! all sports !ractures occurred in the distal part o! the radius. 22 Ho0ever, Mathison and A-ra0al attest that this increase ma be due to an improved access to 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 bo s than in -irls.12,1' In the 1>(0Cs, the pea/ rate o! !ractures o! the distal radius 0as !ound to occur durin- the start o! pubert , bet0een the a-es o! 10 to 12.@ A stud in 1>#> !ound the pea/ a-e to be speci!icall bet0een 11.'&12.' ears old !or -irls and 13.'&12.' ears old !or bo s,23 0hile more recent data su--ests that !or -irls the pea/ a-e is an 0here !rom #&11 and !or bo s !rom 11&12.1> 5sin- current data !rom the NHAMC6, Chun- and 6pilson recentl documented this pea/ !or the pediatric population, and noted a similar trend $3i-ure 3%. A!ter this pea/ rate o! occurrence, the !re8uenc o! distal radius !ractures conse8uentl lo0ers, and is then onl e7ceeded b the incidence rates in 0omen '0 ears o! a-e and older.23 Althou-h it mi-ht seem lo-ical to attribute the causes o! this pea/ rate durinpubert to an increase in ph sical activit , it is /no0n that activit levels tend to decrease as children pro-ress throu-h pubert .22 Aather, the pea/ rate o! !ractures appears to be closel correlated to the bone mineral densit and bone mineral content o! the distal radius durinthe pubescent -ro0th spurt. 6tudies have con!irmed a lar-e dissociation bet0een s/eletal -ro0th and minerali:ation durin- pubert , 0hich ma account !or the increased !ra-ilit o! bones seen durin- this sta-e o! development.23,2'&2# In an earl stud on the sub*ect, =rabbe et al. !ound that durin- the pubescent -ro0th spurt, children e7perience lar-e, sudden advances in linear development, or bone len-thenin-, concurrent 0ith ver small increases in bone mineral content.2' 4he

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process o! bone minerali:ation cannot /eep up 0ith the abrupt increase in ne0 bone development, resultin- in bones that are particularl susceptible to !racture. A!ter pubert , linear development be-ins to slo0, and bone mineral content be-ins to increase rapidl , creatin- stron-er bones that are more resistant to trauma. A an et al. !ound a statisticall si-ni!icant hi-her proportion o! in*uries due to minor trauma in the 10&12 a-e -roup 0hen compared to the '&> a-e -roup.12 4his ma su--est that a 0ea/ened s/eletal structure due to lo0 rates o! bone minerali:ation durin- the adolescent -ro0th spurt leaves even a minor trauma 0ith the potential to cause a distal radius !racture. Additionall , some su--est there ma be a brie! period o! increased cortical porosit durinthe adolescent -ro0th spurt to allo0 !or e!!icient absorption o! calcium re8uired b the bones durin- this rapid sta-e o! -ro0th.2> Prior to minerali:ation, the increased bone porosit ma contribute to the pea/ rate o! distal radius !ractures seen durin- this period o! rapid ph siolo-ical development. +ender and Ethnicity 4he incidence rate o! distal radius !ractures is /no0n to be hi-her in bo s than in -irls. A stud b A an et al. demonstrated a statisticall si-ni!icant di!!erence bet0een the incidence rates o! bo s and -irls, 0ith (2. o! all !ractures occurrin- in bo s.12 Ether studies have sho0n 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!icant di!!erence in the rate bet0een urban and rural pediatric populations.1> Mechanism of )n,ury 4he mechanism o! in*ur in distal radius !ractures in the pediatric population has been 0ell documented. 4he main t pes o! activities causin- distal radius !ractures in children are sports, car accidents, and pla in-. =hosla et al. !ound that !rom 1>>> to 2001, 10. o! all pediatric distal radius !ractures in Elmsted Count occurred 0hile children 0ere usinpla -round e8uipment.1> +ata !rom A an et al. documented 30. o! distal radius !ractures resultin- !rom sports related in*uries in the 10&12 a-e -roup, 0hile sports 0ere responsible !or 2@. o! these !ractures in the 1'&1@ a-e -roup. 4he most common mechanism o! in*ur 0as !all related, 0ith studies sho0in- around #0. o! in*uries occurrin- in this !ashion. 12,30

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-oung 'dult )ncidence

4he incidence o! distal radius !ractures in the adult population is si-ni!icantl lo0er than in other a-e -roups.31 As a result o! this lo0er incidence, and the apparent random occurrence o! !ractures in this lo0 ris/ -roup, little data is available on this population re-ardin- the epidemiolo- o! this in*ur . Ho0ever, even at a lo0 rate, the complications !ollo0in- this in*ur can result in lastin- disabilit in previousl oun-, health individuals. Althou-h in!re8uent, these !ractures are still the most common in*ur in the oun- adult population.32 6ports and car accidents are /no0n to be one o! the most common causes o! distal radius !ractures in oun- adults. +ender and Ethnic differences Aesearch has sho0n that 0hite 0omen have hi-her rates o! distal radius !ractures in individuals above the a-e o! (', a trend not apparent in oun-er adults.33,32 Dro-ren et al. !ound that in the a-e -roup o! 1>&2>, men and 0omen had almost identical incidence rates. Ho0ever, 0hen loo/in- at the a-e -roup !rom 1>&(', 0omen had almost double the rate 0hen compared to men, li/el o0in- to the onset o! osteoporosis in 0omen over '0 ears old.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 than Caucasians, this ma account !or the discrepanc in the published rates o! ethnic di!!erences in distal !orearm !ractures.

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Elderly )ncidence
+istal radius !ractures account !or up to 1#. o! all !ractures in the over1(' 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 0ill prove to be a strain to the medical s stem over the ne7t several decades due to the e7plosive -ro0th o! the elderl population.12 Most !ractures occurrin- in the elderl are the result o! trauma due to a lo0 ener- !orce, 0ith a !all !rom a standin- hei-ht the leadin- cause o! in*ur .3(,3@ Man o! the accidents causin- these lo0 ener- !ractures occur as an individual tries to stop a !all 0ith a dorsall outstretched hand. <vidence has also sho0n that distal radius !ractures seem to occur more o!ten in co-nitivel intact individuals as opposed to those 0ith si-ni!icant dementia. 9omen 0ith -ood neuromuscular control and !aster 0al/in- speeds 0ere !ound to be at hi-her ris/ !or distal radius !racture, as the tend to Greach1outH to brea/ a !all, rather than !all onto the side o! their arm or le-, 0hich 0ould result in a pro7imal humerus or hip !racture. 13,3# 'ge and +ender A-e and -ender have a pronounced e!!ect on the incidence rates o! distal radius !ractures in the elderl communit . 9omen are /no0n to have a si-ni!icantl -reater ris/ o! this in*ur than men in this a-e -roup, as compared to the opposite trend !ound in the pediatric population. Daron et al. !ound that one o! the lar-est -ender discrepancies occurred in the distal !orearm, 0hen loo/in- at !racture rates in the over (' a-e -roup.3' Accordin- to the data, the 0omen in this stud 0ere appro7imatel 2.## times more li/el than men to obtain a distal !orearm !racture. 4his is in direct contrast to rate ratios in other re-ions o! the upper e7tremit , 0here 0omen had a ris/ !actor o! around onl 3 times that o! men. Dro-ren et al. also documented comparable di!!erences bet0een elderl men and 0omen, !indin- 0omen had a hi-her overall incidence, 0ith almost ' times more !ractures in 0omen than in men.31 4he noted that the incidence !or 0omen increased rapidl !rom '0 ears o! a-e and older, almost doublin- ever 10 ears until >0 ears o! a-e $3i-ure 2%. 4he incidence in men remained lo0 until #0 ears o! a-e, but despite this increase, still remained si-ni!icantl lo0er than the rates seen in 0omen. 3lin//ila et al. too/ a closer loo/ at this trend, brea/inthe a-e -roups into ' ear increments, and !ound a similar trend $3i-ure '%. *steoporosis Esteoporosis and osteopenia are common de-enerative bone diseases that pla-ue the elderl population. 4he are caused b a reduced capacit to build and remodel bone. 4he 9orld Health Er-ani:ation de!ines osteoporosis as an individual 0ith a bone mineral densit I2.' standard deviations or less than that o! a matched adult, 0hereas osteopenia !alls bet0een osteoporosis and normal bone densit !or a-e matched controls.3> Bo0 bone mineral densit has been 0ell documented in elderl 0omen 0ho su!!er a distal radius !racture.20&2' A recent stud b J en et al. !ound that decreased bone mineral densit 0as a better predictor o! the ris/ o! distal radius !ractures in 0omen than in men, but a si-ni!icant predictor in both men and 0omen once osteoporosis 0as dia-nosed.23 Cla ton et al. recentl documented the relationship bet0een osteoporosis and the severit o! distal radius !ractures.2( 4his stud indicated that less bone mineral densit 0as correlated 0ith more severe, intra1articular !ractures. It also revealed that a decrease in bone mineral densit is related to an increase in the probabilit o! earl instabilit a!ter closed reduction,

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0ith a ((. chance in the osteoporosis -roup compared to onl a 2#. chance in the normal -roup. Additionall , the !ound that the probabilit o! late carpal malali-nment 0as 3'. in the osteoporosis -roup but onl 2'. in the normal -roup.

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Pediatric *utcomes
'ge In s/eletall immature individuals, anatomic reduction o! distal radius !ractures is usuall not re8uired due to the potential !or -ro0th and remodelin-, and operative intervention is seldom 0arranted. 4his !racture is rarel intra1articular, allo0in- !or initial imper!ect reductions to be 0ell1tolerated. It is accepted that distal !ractures have a more !avorable pro-nosis than those in a more pro7imal aspect o! an e7tremit . Ebservational studies indicate displacement o! ver distal !ractures in patients o! all a-es is better tolerated than more pro7imal malunions in even ver oun- children.2@,2# Dased on lon-1term !unctional outcomes o! malunions in pediatric !orearm !ractures, Noonan et al. made a series o! recommendations !or reduction in pediatric patients presentin- 0ith this in*ur . 3or patients less than > ears old, reduction could be accepted 0ith complete displacement $ba onet apposition% and up to 1cm o! shortenin-, 1' de-rees o! an-ulation, and 2' de-rees o! malrotation, 0ithout resultin- in !unctional de!icits. In children > ears o! a-e and older, 30 de-rees o! malrotation is acceptable, 0ith 10 de-rees o! an-ulation !or pro7imal !ractures and 1' de-rees !or more distal !ractures. 2> Complete ba onet apposition is acceptable, especiall !or distal radius !ractures, as lon- as an-ulation does not e7ceed 20 de-rees and 2 ears o! -ro0th remains.2> &omplications It is important to note that children 0ith distal radius !ractures have particularl lo0 rates o! complications,3,'0 o!ten attainin- superior outcomes 0ith castin- alone. 4his results !rom the !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. A recent stud sho0ed that onl 1@ out o! 30' distal radius !ractures in children had a complication.'0 4he tendenc o! sur-eons to strive !or per!ect anatomic reduction in patients 0ith distal radius !ractures has caused debate over the appropriate treatment protocol !or children 0ith these in*uries. A stud b +o et al. compared the !unctional outcomes o! children 0ith distal radius !ractures 0ho under0ent closed reduction and those 0ho had onl splint stabili:ation.'1 4he 32 children 0ho had no attempted reduction had the same !unctional results at their !ollo01up visits as the 32 children 0ho under0ent reduction. In addition, the !ound the total cost !or patients 0ith attempted reduction to be '0. more than those 0ithout reduction, even thou-h both -roups achieved the same !unctional outcomes 0ith no complications at their !ollo01up visits. A more recent stud b Al1Ansari et al. sho0ed that 0 out o! 122 children 0ith minimall an-ulated distal radius !ractures re8uired sur-ical intervention or manipulation o! an t pe be!ore a cast 0as applied.30 En occasion, pediatric distal radius !ractures are accompanied b distal ulna !ractures. Most studies to date have not separated outcomes !rom isolated distal radius !ractures !rom those that include a distal ulna !racture $complete or incomplete%.2@ 6 nostosis is a rare but di!!icult to treat complication in this t pe o! in*ur . 4hose most at ris/ are individuals 0ith hi-h ener- trauma or those 0ith a concomitant head in*ur .'2 Ae1!racture at the same site !ollo0in- a distal radius !racture is not in!re8uent i! the immobili:ation is removed too earl and the child returns to activities be!ore the lamellar bone has !ull remodeled. Eutcomes !ollo0in- re1!racture have been documented as havin- 0orse clinical outcomes than !ractures that have healed primaril .2@,'3 6peci!icall !or -irls 0ith lo0 bone mass densit $DM+% and a previous distal !orearm !racture, the ris/ o! another distal radius !racture 0as

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sho0n to be 2 times -reater than controls, since bone mineral deposition la-s behind increases in bod 0ei-ht and bone len-th.'2

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-oung 'dult *utcomes

Ence patients have reached s/eletal maturit , most e7tra1articular distal radius !ractures have -ood lon-1term !unctional results 0ith conservative treatment i! initiall reduced to restore anatomic hei-ht and inclination. In a 301 ear !ollo01up stud o! oun- adults in 60eden 0ith distal radius !ractures, the !ound that o! the 2#. o! stud participants 0ho had e7tra1articular !ractures $avera-e a-e o! 31 at time o! !racture, ran-e 1#&20%, onl 3@. had even minor complaints o! pain, decreased mobilit , or cosmetic de!ormit . '' It is di!!icult to obtain satis!actor results 0ith intra1articular distal radius !ractures in ounadults. 4his is due to the development o! s mptomatic post1traumatic arthritis i! treated non1 operativel , 0ith rates reported as hi-h as 20..''&'@ In =nir/ and KupiterCs 1>#( stud o! intra1articular !ractures in oun- adults $avera-e a-e at !racture o! 2# ears% treated either 0ith cast immobili:ation or pins and plaster, the sa0 radio-raphic evidence o! arthritis in ('. o! patients at @ ears !ollo01up. Ninet 1three percent o! those 0ith radio-raphic arthritis 0ere s mptomatic, 0hich the asserted 0ere most commonl the result o! a malreduced die1punch !ra-ment.'# Catalano et al studied 21 patients oun-er than the a-e o! 2' ears 0ho had under-one internal !i7ation o! displaced intra1articular !ractures. At an avera-e o! @ ears, osteoarthrosis o! the radiocarpal *oint 0as radio-raphicall apparent in @(. o! 0rists.'> 4he abilit o! oun- adults to return to 0or/ !ollo0in- a distal radius !racture ma be one o! the most ob*ective parameters b 0hich to assess the epidemiolo-ic impact o! these in*uries on this population. In =nir/Cs paper, onl one o! the 20 patients 0as unable to return to their prior occupation due to the residual e!!ects o! their distal radius !racture. (0 In CatalanoCs stud , onl 1 o! 21 patients 0as unable to continue her current pro!ession as a nurse.'> Althou-h rates o! post1traumatic arthritis ma be hi-h in these oun-er adults, data su--ests that these reported s mptoms 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 !ollo0in- a distal radius !racture. Ho0ever, these !actors are o!ten interconnected and di!!icult to isolate !or evaluation !rom an epidemiolo-ic perspective. Ene o! the ma*or limitin- !actors in e7aminin- these outcomes is that !e0 studies desi-nate 0hether the !racture has intra1articular e7tension. 4his seems to be emer-in- as an important !actor !or re-ainin- !unctional motion and stren-th, rather than absolute measures o! !racture ali-nment and malunion. Mortality and Functional Decline +istal radius !ractures can be a si-ni!icant source o! mortalit and loss o! independence in the elderl . In e7aminin- the !unctional status o! a prospective cohort o! >,000 older 0omen !ollo0ed throu-h the 6tud !or Esteoporotic 3ractures, 0omen 0ith a 0rist !racture 0ere '0. more li/el than those 0ithout !ractures to have a clinicall important !unctional decline. 4his decline 0as practicall de!ined b 0orsenin- 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 0ith a distal radius !racture, compared to a standard 56 matched control -roup, 0ere sho0n to be si-ni!icantl hi-her than those o! the standard 56 elderl population, an avera-e o! a 12.

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increase @ ears a!ter the !racture.(1 In this stud , men 0ith a distal radius !racture 0ere !ound to be 2.(' times more li/el to die in this time period than 0omen 0ith this !racture, li/el due in part b the lar-est increase in incidence in men occurrin- in the over1#0 ear old 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 0orse outcomes than the same !racture in a 0oman. 'g e

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Previous radio-raphic parameters !or acceptable reductions in displaced distal radius !ractures had been developed usin- a sub1set o! oun-er, more active patients. In Karme/o et alCs stud in 200@, the asserted that these !actors had not been appropriatel validated !or the Gelderl H in their stud $avera-e a-e o! (#.'% and had little e!!ect on sel!1reported !unctional outcomes in short1term !ollo01up in non1operative cases.(2 In a retrospective stud o! 112 patients $avera-e a-e o! @>% 0ho met operative criteria !or unstable distal radius !racture, but !or 0hom (3 declined sur-er , Mattila !ound no si-ni!icant di!!erences at ' ears in !unctional outcomes or pain.(3 A recent meta1anal sis o! more than 1,000 distal radius !ractures comparin- cast immobili:ation to an operative treatment in patients older than (0 has sho0n that despite 0orse radio-raphic outcomes associated 0ith castin-, !unctional outcomes 0ere 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 the treatment o! distal radius !ractures.(3,(2 Althou-h this mi-ht appear to be directl correlated 0ith the increased incidence o! these !ractures seen in recent ears, no evidence is available to support such a claim. Matilla et al !ound that bet0een 1>># and 200#, the use o! sur-ical intervention !or the treatment o! distal radius !ractures doubled.(3 4he also !ound an increase in the use o! internal !i7ation over other techni8ues, 0hich more than doubled over the 11 ear period o! the stud . A recent ten1 ear revie0 o! Medicare data conducted b Chun- et al. documented trends in the treatment o! distal radius !ractures in the elderl .(2 4he !ound that closed !i7ation 0as the 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 0as also documented that distal radius !ractures are increasin-l bein- treated b hand sur-eons, 0ith rates increasin- !rom . #. to 3.>. durin- the stud period. Additionall , hand sur-eons 0ere sho0n to be more li/el to use internal !i7ation in the treatment o! these !ractures. In contrast, orthopaedic sur-eons 0ere !ound to be '.@ times more li/el than hand sur-eons to use closed treatment. 4his coincides 0ith a stud b =oval et al. sho0in- hand sur-eons leanin- to0ards the use o! internal !i7ation over closed treatment.(' 4here is evidence that over '0. o! !ractures treated 0ith closed reduction are pla-ued b malunion, 0hich hi-hli-hts the importance that distal radius !ractures should be evaluated on a case b case basis.((,(@ 4he increased tendenc !or sur-ical manipulation in recent ears has been coupled 0ith a shi!t in !avor o! open reduction and internal !i7ation over other treatment options. Althou-h this ne0 treatment is e7citin-, no conclusive evidence has sho0n it to be more e!!ective than an other treatment protocol. It is not clear 0h this increase is occurrin-, but it ma be because more distal radius !ractures are bein- treated b hand sur-eons. It also ma be the result o! increasin-l success!ul mar/etin- schemes directed to0ards sur-eons, or even *ust the e7citement that comes 0ith the novelt o! a ne0 technolo- . 9hatever the case, numerous studies have made it clear that there is no si-ni!icant di!!erence bet0een the lonterm !unctional outcomes o! EAI3 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 short term outcomes, the lon- term results remained the same.

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6ee/in- to ans0er some o! these di!!icult sur-ical treatment 8uestions in the elderl , the 9AI64 $9rist and Aadius In*ur 6ur-ical 4rial% stud -roup 0as !ormed in 200>, comprised o! 1> centers across North America 0ith participation !rom both plastic and orthopaedic 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 to other !orms o! sur-ical !i7ation throu-h a multi1center clinical trial $MCC4%. 4his MCC4 desi-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 bet0een 1>># and 2002 sho0ed internal !i7ation rates close to doublin- !rom '. to #. nationall across all a-es. More interestin-l , the t pe o! operative !i7ation 0as e7tremel variable bet0een hospital re!erral re-ions, 0ith internal !i7ation ran-in- !rom .2. to 2'. in some areas. @3 4hese ma*or di!!erences in treatment rates are not une7pected -iven the variabilit in !racture patterns at the distal radius, numerous treatment options available, and the lac/ o! consensus in the literature re-ardin- treatment outcomes. 4he most recent article to e7plore the use o! internal !i7ation !or distal radius !ractures in the Medicare population e7amined re-ional variations, ethnic variabilit and treatin- ph sician characteristics to better understand the !actors contributin- to the chan-in- trends. @2 In 200@, the !ound nearl #(,000 Medicare patients su!!ered a closed distal radius !racture, o! 0hich 1@. 0e treated 0ith internal !i7ation. 4his is over t0o times the rate o! internal !i7ation !rom a ( ear time period endin- *ust 3 ears prior to the stud . 4he also !ound men 0ere si-ni!icantl less li/el to receive internal !i7ation than 0omen, as 0ere blac/s compared to 0hites. Bi/e the +artmouth stud , the also sa0 nearl a 101!old di!!erence in the rates o! internal !i7ation across di!!erent hospital re!erral re-ions. 4he stud then e7amined these di!!erences b re-ion based on 0hether the patient 0as treated b a hand sur-eon, !indin- si-ni!icant positive correlations 0ith 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! underl in- osteoporosis, and the event represents a prime point !or intervention. In the ear !ollo0in- a distal radius !racture, studies have sho0n ' and10 times -reater rates o! vertebral !ractures in 0omen and men respectivel , in accordance 0ith a (0. increase in the rates o! hip !ractures !or 0omen 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 initiatives in the active elderl have been both success!ul and cost1e!!ective in preventin- distal radius !ractures.@(,@@ Ether simple preventative measures include 0arnin-s !or dan-erous 0eather conditions and clearin- or preventin- accumulation o! sno0 and ice in order to decrease the incidence 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 and treatment o! bone diseases such as osteoporosis and osteopenia. Ho0ever, in a stud o! 111 patients in the militar medical s stem to determine rates o! osteoporosis !ollo0 up in the ear !ollo0in- a distal radius !racture, it 0as discovered that onl ((. received some sort o! intervention !or osteoporosis. Ene 8uarter o! the patients 0ere re!erred to endocrinolo- , 20. had a +<LA scan, 0hile onl 2@. had been ta/in- some sort o! medication to treat their osteoporosis.@#

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4he use o! bisphosphonates in combination 0ith supplements such as Calcium and Mitamin + has been sho0n to help decrease the ris/ o! !ractures due to osteopenia and osteoporosis. Disphosphonates $DPs% are the most common therap protocol !or the treatment o! bone resorption due to the e!!ects o! osteoporosis and other bone diseases.@>&#' Esteoporosis is a leadin- ris/ !actor !or distal radius !ractures, and the use o! DPs has pla ed an important role in reducin- this ris/. Aesearch is currentl providin- ne0 insi-hts into the e7act mechanism o! action that -ives DPs their anti1resorptive properties.#( Disphosphonates are able to increase bone mineral calcium throu-h the inhibition o! osteoclastic bone resorption b alterin- upstream di!!erentiation o! osteoc tes in addition to promotin- the apoptosis o! these osteoclasts.#@ +ue to the suppressive actions the have on bone remodelin-, it 0as ori-inall theori:ed that DPs 0ould disrupt the healin- process o! !ractures. It has been sho0n that this is not the case, and in !act DPs stimulate bone remodelin- b promotin- the recruitment and activit o! osteoblasts and osteoc tes, 0hile decreasin- apoptosis o! these cells.## 4his activit causes an increase in bone mineral densit , 0hich can result in up to a '0. decrease in the ris/ o! !uture !ractures. #> A recent stud !ound less than a one 0ee/ di!!erence in the rate o! distal radius !racture healin- !or those ta/in- DPs and those not ta/in- them $'' da s versus 2> da s%, a di!!erence !elt to be not clinicall si-ni!icant>0 Aecent reports have hi-hli-hted that bisphosphonate treatment is not 0ithout ris/, despite an estimated 30 million individuals prescribed bisphosphonate therap per ear in the 56 alone.>1 =no0n esopha-eal irritation is common, but at pical sub1trochanteric !emur !ractures are increasin-l bein- reported, primaril in the settin- o! lon-1term bisphosphonate use.>2&>2 Esteonecrosis o! the *a0 has also been reported to occur in up to . 02. o! osteoporotic patients on bisphosphonate therap .>' 4he dose dependenc e!!ect is no0 more clearl de!ined, but the e7act patho-enic role o! bisphosphonates in these at pical bone events remains unclear. 4he ph sician must 0ei-h the ris/s and bene!its 0ith the patient, but the absolute ris/ o! at pical !racture associated 0ith bisphosphonate use compared 0ith the hi-h ris/ o! osteoporotic !ractures is small, 0hen 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. It 0ould not be cost e!!ective to dia-nose and treat ever one, so it is essential that onl those at hi-h ris/ !or osteoporosis should be evaluated and treated.

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&onclusion
Possessin- a /no0led-e o! the incidence and outcomes o! distal radius !ractures allo0s the ph sician to better counsel individual patients and determine the best mana-ement to optimi:e treatment. Althou-h treatment outcomes !or pediatric and oun- adults are !airl 0ell de!ined !or distal radius !ractures, recent research in the elderl population has made decision1ma/in- !or the patient and sur-eon more comple7. It is becomin- increasin-l di!!icult to de!ine the di!!erence bet0een the active GolderH adult that 0ill continue to place hi-h demands on an in*ured 0rist, and the true Gelderl H that ma better adapt to an imper!ect outcome. Bar-e multi1center studies, such as the 9AI64 stud , 0ith lon-1term !ollo01up ma be the onl 0a to accuratel delineate the best treatment options !or an individual 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 and Musculos/eletal and 6/in +iseases $A01 AA0(20((% and !rom the National Institute o! Arthritis and

Nellans et al.

Pa-e 11 Musculos/eletal and 6/in +iseases $2A01 AA02@32#10(% and a Midcareer Investi-ator A0ard in Patient1Eriented Aesearch $=22 AA0'3120% $to +r. =evin C. Chun-%.

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#(. Bomashvili =A, Monier13au-ere MC, 9an- L, Malluche HH, EPNeill 9C. <!!ect o! bisphosphonates on vascular calci!ication and bone metabolism in e7perimental renal !ailure. =idne Int. 200>; @'"(1@&(2'. NPubMed" 1>12>@>3O #@. Hu-hes +<, 9ri-ht =A, 5 HB, et al. Disphosphonates promote apoptosis in murine osteoclasts in vitro and in vivo. K Done Miner Aes. 1>>'; 10"12@#&12#@. NPubMed" #(#('03O ##. Plot/in BI, 9einstein A6, Par!itt AM, Aoberson P=, Manola-as 6C, Dellido 4. Prevention o! osteoc te and osteoblast apoptosis b bisphosphonates and calcitonin. K Clin Invest. 1>>>; 102"13(3&13@2. NPubMed" 10'(22>#O #>. Harris 64, 9atts ND, Renant H=, et al. <!!ects o! risedronate treatment on vertebral and nonvertebral !ractures in 0omen 0ith postmenopausal osteoporosis" a randomi:ed controlled trial. Mertebral <!!icac 9ith Aisedronate 4herap $M<A4% 6tud Rroup. KAMA. 1>>>; 2#2"1322& 13'2. NPubMed" 10'2@1#1O >0. Ao:ental 4+, Ma:8ue: MA, Chac/o A4, A o-u N, Dou7sein MB. Comparison o! radio-raphic !racture healin- in the distal radius !or patients on and o!! bisphosphonate therap . K Hand 6urAm. 200>; 32"'>'&(02. NPubMed" 1>32'#(1O >1. Masoodi NA. Eral Disphosphonates and the Ais/ !or Esteonecrosis o! th Eral Disphosphonates and the Ais/ !or Esteonecrosis o! the Ka0 e Ka0. Dritish K o! Medical Practitioners. 200>; 2 >2. Benart DA, Borich +R, Bane KM. At pical !ractures o! the !emoral diaph sis in postmenopausal 0omen ta/in- alendronate. Ne0 <n-land Kournal o! Medicine. 200#; 3'#"1302&130(. NPubMed" 1#3'2112O >3. Ai::oli A, X/esson =, Dou7sein M, et al. 6ubtrochanteric !ractures a!ter lon-1term treatment 0ith bisphosphonates" a <uropean societ on clinical and economic aspects o! osteoporosis and osteoarthritis, and international osteoporosis !oundation 0or/in- -roup report. Esteoporosis International. 2011"1&1#. >2. 6chilcher K, MichaYlsson =, Aspenber- P. Disphosphonate use and at pical !ractures o! the !emoral sha!t. N<KM. 2011; 3(2"1@2#&1@3@. NPubMed" 21'22@23O >'. Cartsos MM, Shu 6, Savras AI. Disphosphonate use and the ris/ o! adverse *a0 outcomes" a medical claims stud o! @12,21@ people. K o! the Am +ental Assn. 200#; 13>"23&30.

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Figure 1.

4he increasin- incidence o! distal radius !ractures in bo s and -irls under the a-e o! 20. 4he rise in incidence 0as statisticall si-ni!icant !or both bo s and -irls. +ata !rom =hosla et al., Incidence o! Childhood +istal 3orearm 3ractures Ever 30 Qears. Ae!. 20

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Figure 2.

A stron- increase in the incidence o! sports related !ractures 0as !ound in the pediatric population, 0hich ma account !or the rise in the overall incidence rates o! distal radius !ractures. +ata !rom Putter et al., 4rends in 9rist 3ractures in Children and Adolescents, 1>>@&200>. Ae!. 3

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Figure 3.

4his sho0s the combined pea/ rate o! !ractures o! both bo s and -irls to be around 10 ears old, correspondin- to pea/ rates documented in other studies. +ata !rom Chun- and 6pilson, 4he 3re8uenc and <pidemiolo- o! Hand and 3orearm 3ractures in the 5nited 6tates. Ae!. 1

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Figure 4.

Incidence rate o! distal radius !ractures per 10,000 people in men and 0omen a-ed 1> to #0. 4he increasin- incidence 0as statisticall si-ni!icant 0hen comparin- the three a-e -roups in both men and 0omen. +ata !rom Dro-ren et al., Incidence and Characteristics o! +istal Aadius 3ractures in a 6outhern 60edish Ae-ion. Ae!. 32

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Figure 5.

Incidence rate o! distal radius !ractures per 100,000 people in men and 0omen a-ed 1( to #0. A statisticall si-ni!icant di!!erence 0as documented bet0een the overall incidence o! men and 0omen, 0ith 0omen havin- a hi-her rate o! !racture. +ata !rom 3lin//ila et al., <pidemiolo- and 6easonal Mariation o! +istal Aadius 3ractures in Eulu, 3inland. Ae!. 3@