Assessment of Anatomic Restoration of Distal Radius Fractures Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial | Orthopedics | JAMA Network Open | JAMA Network
[Skip to Navigation]
Sign In
Figure.  Multivariable 2-Phase Regression Plots
Multivariable 2-Phase Regression Plots

The shaded area indicates the 95% CI. Vertical line indicates the normal value for each independent variable (eg, for panel A, the vertical line is at X = 22, which is the accepted normal value for radial inclination). ADL indicates activities of daily living; MHQ, Michigan Hand Outcomes Questionnaire.

Table 1.  Study Cohort Characteristics by Age Group
Study Cohort Characteristics by Age Group
Table 2.  Testing the 2-Phase Model Fit for Association of Radial Inclination, Ulnar Variance, and Tilt With Patient Outcomesa
Testing the 2-Phase Model Fit for Association of Radial Inclination, Ulnar Variance, and Tilt With Patient Outcomesa
Table 3.  Two-Phase Association Between Radiographic Measures and Functional Outcomes at 12 Months Following Treatmenta
Two-Phase Association Between Radiographic Measures and Functional Outcomes at 12 Months Following Treatmenta
Table 4.  Two-Phase Association Between Radiographic Measures and Patient-Reported Outcomes at 12 Months Following Treatmenta
Two-Phase Association Between Radiographic Measures and Patient-Reported Outcomes at 12 Months Following Treatmenta
1.
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):2154-2162. doi:10.2106/JBJS.J.012802PubMedGoogle ScholarCrossref
2.
Levin  LS, Rozell  JC, Pulos  N.  Distal radius fractures in the elderly.  J Am Acad Orthop Surg. 2017;25(3):179-187. doi:10.5435/JAAOS-D-15-00676PubMedGoogle ScholarCrossref
3.
MacDermid  JC, Roth  JH, Richards  RS.  Pain and disability reported in the year following a distal radius fracture: a cohort study.  BMC Musculoskelet Disord. 2003;4:24. doi:10.1186/1471-2474-4-24PubMedGoogle ScholarCrossref
4.
Burge  R, Dawson-Hughes  B, Solomon  DH, Wong  JB, King  A, Tosteson  A.  Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025.  J Bone Miner Res. 2007;22(3):465-475. doi:10.1359/jbmr.061113PubMedGoogle ScholarCrossref
5.
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):237-242. doi:10.1097/BOT.0b013e31819b24e9PubMedGoogle ScholarCrossref
6.
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):1612-1620. doi:10.1007/s11999-008-0660-2PubMedGoogle ScholarCrossref
7.
Simic  PM, Weiland  AJ.  Fractures of the distal aspect of the radius: changes in treatment over the past two decades.  Instr Course Lect. 2003;52:185-195. doi:10.2106/00004623-200303000-00026PubMedGoogle Scholar
8.
Gehrmann  SV, Windolf  J, Kaufmann  RA.  Distal radius fracture management in elderly patients: a literature review.  J Hand Surg Am. 2008;33(3):421-429. doi:10.1016/j.jhsa.2007.12.016PubMedGoogle ScholarCrossref
9.
Beumer  A, McQueen  MM.  Fractures of the distal radius in low-demand elderly patients: closed reduction of no value in 53 of 60 wrists.  Acta Orthop Scand. 2003;74(1):98-100. doi:10.1080/00016470310013743PubMedGoogle ScholarCrossref
10.
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. doi:10.1053/jhsu.2000.jhsu025a0019PubMedGoogle ScholarCrossref
11.
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):1121-1127. doi:10.1016/j.jhsa.2004.07.002PubMedGoogle ScholarCrossref
12.
McQueen  M, Caspers  J.  Colles fracture: does the anatomical result affect the final function?  J Bone Joint Surg Br. 1988;70(4):649-651. doi:10.1302/0301-620X.70B4.3403617PubMedGoogle ScholarCrossref
13.
Medicare Enrollment Dashboard Data File. Centers for Medicare & Medicaid Services. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMSProgramStatistics/Dashboard.html. Accessed December 28, 2018.
14.
Manton  KG, Gu  X, Lamb  VL.  Change in chronic disability from 1982 to 2004/2005 as measured by long-term changes in function and health in the US elderly population.  Proc Natl Acad Sci U S A. 2006;103(48):18374-18379. doi:10.1073/pnas.0608483103PubMedGoogle ScholarCrossref
15.
Toosi  M, Torpey  E. Older workers: Labor force trends and career options. United States Department of Labor Bureau of Labor Statistics website. https://www.bls.gov/careeroutlook/2017/article/older-workers.htm. Accessed March 18, 2019.
16.
Morris  NS.  Distal radius fracture in adults: self-reported physical functioning, role functioning, and meaning of injury.  Orthop Nurs. 2000;19(4):37-48. doi:10.1097/00006416-200019040-00008PubMedGoogle ScholarCrossref
17.
Bialocerkowski  AE.  Difficulties associated with wrist disorders—a qualitative study.  Clin Rehabil. 2002;16(4):429-440. doi:10.1191/0269215502cr516oaPubMedGoogle ScholarCrossref
18.
Fried  TR, Bradley  EH, Towle  VR, Allore  H.  Understanding the treatment preferences of seriously ill patients.  N Engl J Med. 2002;346(14):1061-1066. doi:10.1056/NEJMsa012528PubMedGoogle ScholarCrossref
19.
Grewal  R, MacDermid  JC.  The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients.  J Hand Surg Am. 2007;32(7):962-970. doi:10.1016/j.jhsa.2007.05.009PubMedGoogle ScholarCrossref
20.
Grewal  R, MacDermid  JC, Pope  J, Chesworth  BM.  Baseline predictors of pain and disability one year following extra-articular distal radius fractures.  Hand (N Y). 2007;2(3):104-111. doi:10.1007/s11552-007-9030-xPubMedGoogle ScholarCrossref
21.
Lalone  EA, Grewal  R, King  GJ, MacDermid  JC.  A structured review addressing the use of radiographic measures of alignment and the definition of acceptability in patients with distal radius fractures.  Hand (N Y). 2015;10(4):621-638. doi:10.1007/s11552-015-9772-9PubMedGoogle ScholarCrossref
22.
Kreder  HJ, Hanel  DP, McKee  M, Jupiter  J, McGillivary  G, Swiontkowski  MF.  X-ray film measurements for healed distal radius fractures.  J Hand Surg Am. 1996;21(1):31-39. doi:10.1016/S0363-5023(96)80151-1PubMedGoogle ScholarCrossref
23.
Macdermid  JC, Richards  RS, Donner  A, Bellamy  N, Roth  JH, Hildebrand  KA.  Reliability of hand fellows’ measurements and classifications from radiographs of distal radius fractures.  Can J Plast Surg. 2001;9(2):51-58. doi:10.1177/229255030100900204Google ScholarCrossref
24.
Chung  KC, Malay  S, Shauver  MJ, Kim  HM; WRIST Group.  Assessment of distal radius fracture complications among adults 60 years or older: a secondary analysis of the WRIST randomized clinical trial.  JAMA Netw Open. 2019;2(1):e187053-e187053. doi:10.1001/jamanetworkopen.2018.7053PubMedGoogle ScholarCrossref
25.
Waljee  JF, Ladd  A, MacDermid  JC, Rozental  TD, Wolfe  SW; Distal Radius Outcomes Consortium.  A unified approach to outcomes assessment for distal radius fractures.  J Hand Surg Am. 2016;41(4):565-573. doi:10.1016/j.jhsa.2016.02.001PubMedGoogle ScholarCrossref
26.
Trampisch  US, Franke  J, Jedamzik  N, Hinrichs  T, Platen  P.  Optimal Jamar dynamometer handle position to assess maximal isometric hand grip strength in epidemiological studies.  J Hand Surg Am. 2012;37(11):2368-2373. doi:10.1016/j.jhsa.2012.08.014PubMedGoogle ScholarCrossref
27.
Chung  KC, Pillsbury  MS, Walters  MR, Hayward  RA.  Reliability and validity testing of the Michigan Hand Outcomes Questionnaire.  J Hand Surg Am. 1998;23(4):575-587. doi:10.1016/S0363-5023(98)80042-7PubMedGoogle ScholarCrossref
28.
Kotsis  SV, Lau  FH, Chung  KC.  Responsiveness of the Michigan Hand Outcomes Questionnaire and physical measurements in outcome studies of distal radius fracture treatment.  J Hand Surg Am. 2007;32(1):84-90. doi:10.1016/j.jhsa.2006.10.003PubMedGoogle ScholarCrossref
29.
Graham  TJ.  Surgical correction of malunited fractures of the distal radius.  J Am Acad Orthop Surg. 1997;5(5):270-281. doi:10.5435/00124635-199709000-00005PubMedGoogle ScholarCrossref
30.
Topolski  TD, LoGerfo  J, Patrick  DL, Williams  B, Walwick  J, Patrick  MB.  The Rapid Assessment of Physical Activity (RAPA) among older adults.  Prev Chronic Dis. 2006;3(4):A118.PubMedGoogle Scholar
31.
Taleisnik  J, Watson  HK.  Midcarpal instability caused by malunited fractures of the distal radius.  J Hand Surg Am. 1984;9(3):350-357. doi:10.1016/S0363-5023(84)80222-1PubMedGoogle ScholarCrossref
32.
Arora  R, Lutz  M, Deml  C, Krappinger  D, Haug  L, Gabl  M.  A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older.  J Bone Joint Surg Am. 2011;93(23):2146-2153. doi:10.2106/JBJS.J.01597PubMedGoogle ScholarCrossref
33.
Chen  Y, Chen  X, Li  Z, Yan  H, Zhou  F, Gao  W.  Safety and efficacy of operative versus nonsurgical management of distal radius fractures in elderly patients: a systematic review and meta-analysis.  J Hand Surg Am. 2016;41(3):404-413. doi:10.1016/j.jhsa.2015.12.008PubMedGoogle ScholarCrossref
34.
Egol  KA, Walsh  M, Romo-Cardoso  S, Dorsky  S, Paksima  N.  Distal radial fractures in the elderly: operative compared with nonoperative treatment.  J Bone Joint Surg Am. 2010;92(9):1851-1857. doi:10.2106/JBJS.I.00968PubMedGoogle ScholarCrossref
35.
Mellstrand Navarro  C, Ahrengart  L, Törnqvist  H, Ponzer  S.  Volar locking plate or external fixation with optional addition of k-wires for dorsally displaced distal radius fractures: a randomized controlled study.  J Orthop Trauma. 2016;30(4):217-224. doi:10.1097/BOT.0000000000000519PubMedGoogle ScholarCrossref
36.
Williksen  JH, Frihagen  F, Hellund  JC, Kvernmo  HD, Husby  T.  Volar locking plates versus external fixation and adjuvant pin fixation in unstable distal radius fractures: a randomized, controlled study.  J Hand Surg Am. 2013;38(8):1469-1476. doi:10.1016/j.jhsa.2013.04.039PubMedGoogle ScholarCrossref
37.
Karantana  A, Downing  ND, Forward  DP,  et al.  Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial.  J Bone Joint Surg Am. 2013;95(19):1737-1744. doi:10.2106/JBJS.L.00232PubMedGoogle ScholarCrossref
38.
Plant  CE, Parsons  NR, Costa  ML.  Do radiological and functional outcomes correlate for fractures of the distal radius?  Bone Joint J. 2017;99-B(3):376-382. doi:10.1302/0301-620X.99B3.35819PubMedGoogle ScholarCrossref
39.
Symonette  CJ, MacDermid  JC, Grewal  R.  Radiographic thresholds with increased odds of a poor outcome following distal radius fractures in patients over 65 years old.  JHSGO. 2019;1(2):65-69. doi:10.1016/j.jhsg.2019.02.002Google Scholar
40.
Martinez-Mendez  D, Lizaur-Utrilla  A, de-Juan-Herrero  J.  Intra-articular distal radius fractures in elderly patients: a randomized prospective study of casting versus volar plating.  J Hand Surg Eur Vol. 2018;43(2):142-147. doi:10.1177/1753193417727139PubMedGoogle ScholarCrossref
41.
Batra  S, Gupta  A.  The effect of fracture-related factors on the functional outcome at 1 year in distal radius fractures.  Injury. 2002;33(6):499-502. doi:10.1016/S0020-1383(01)00174-7PubMedGoogle ScholarCrossref
42.
Leung  F, Ozkan  M, Chow  SP.  Conservative treatment of intra-articular fractures of the distal radius—factors affecting functional outcome.  Hand Surg. 2000;5(2):145-153. doi:10.1142/S0218810400000338PubMedGoogle ScholarCrossref
43.
Karnezis  IA, Panagiotopoulos  E, Tyllianakis  M, Megas  P, Lambiris  E.  Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius.  Injury. 2005;36(12):1435-1439. doi:10.1016/j.injury.2005.09.005PubMedGoogle ScholarCrossref
44.
Kodama  N, Takemura  Y, Ueba  H, Imai  S, Matsusue  Y.  Acceptable parameters for alignment of distal radius fracture with conservative treatment in elderly patients.  J Orthop Sci. 2014;19(2):292-297. doi:10.1007/s00776-013-0514-yPubMedGoogle ScholarCrossref
45.
Gartland  JJ  Jr, Werley  CW.  Evaluation of healed Colles’ fractures.  J Bone Joint Surg Am. 1951;33-A(4):895-907. doi:10.2106/00004623-195133040-00009PubMedGoogle ScholarCrossref
46.
Brogren  E, Wagner  P, Petranek  M, Atroshi  I.  Distal radius malunion increases risk of persistent disability 2 years after fracture: a prospective cohort study.  Clin Orthop Relat Res. 2013;471(5):1691-1697. doi:10.1007/s11999-012-2767-8PubMedGoogle ScholarCrossref
47.
Aro  HT, Koivunen  T.  Minor axial shortening of the radius affects outcome of Colles’ fracture treatment.  J Hand Surg Am. 1991;16(3):392-398. doi:10.1016/0363-5023(91)90003-TPubMedGoogle ScholarCrossref
48.
Handoll  HH, Huntley  JS, Madhok  R.  External fixation versus conservative treatment for distal radial fractures in adults.  Cochrane Database Syst Rev. 2007;(3):CD006194. doi:10.1002/14651858.CD006194.pub2PubMedGoogle Scholar
49.
Handoll  HH, Madhok  R.  Surgical interventions for treating distal radial fractures in adults.  Cochrane Database Syst Rev. 2001;(3):CD003209. doi:10.1002/14651858.CD003209PubMedGoogle Scholar
50.
Handoll  HH, Vaghela  MV, Madhok  R.  Percutaneous pinning for treating distal radial fractures in adults.  Cochrane Database Syst Rev. 2007;(3):CD006080. doi:10.1002/14651858.CD006080.pub2PubMedGoogle Scholar
51.
Gordon  NA, Koch  ME.  Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surgery: a review of 1200 consecutive cases.  Arch Facial Plast Surg. 2006;8(1):47-53. doi:10.1001/archfaci.8.1.47PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    Surgery
    January 17, 2020

    Assessment of Anatomic Restoration of Distal Radius Fractures Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial

    Author Affiliations
    • 1Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor
    • 2Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
    • 3Early Development Statistics, Merck & Co Inc, Rahway, New Jersey
    • 4Department of Biostatistics, University of Michigan, Ann Arbor
    JAMA Netw Open. 2020;3(1):e1919433. doi:10.1001/jamanetworkopen.2019.19433
    Key Points español 中文 (chinese)

    Question  What is the association between radiographic measures of reduction and patient outcomes 12 months after distal radius fractures treatment for adults aged 60 years or older?

    Findings  This secondary analysis of a multicenter randomized clinical trial on distal radius fractures treatment options included 166 patients who completed 12-month assessments. Radiographic parameters were not associated with functional and patient-reported outcomes.

    Meaning  Precise anatomic restoration does not guarantee good outcomes and may not have value in outcome evaluation for older adults with distal radius fractures.

    Abstract

    Importance  The value of precise anatomic restoration for distal radius fractures (DRFs) in older adults has been debated for many decades, with conflicting results in the literature. In light of the growing population of adults aged 60 years and older, both fracture incidence and associated treatment costs are expected to increase.

    Objective  To determine the association between radiographic measures of reduction and patient outcomes after DRF in older patients.

    Design, Setting, and Participants  Data were collected from the Wrist and Radius Injury Surgical Trial (WRIST), a multicenter randomized clinical trial of DRF treatments for adults aged 60 years and older (enrollment from April 10, 2012, to December 31, 2016, with a 2-year follow-up). Data analysis was performed from January 3, 2019, to August 19, 2019. WRIST participants who completed 12-month assessments were included in the study. According to the biomechanical principle of alignment, 2-phase multivariable regression models were adopted to assess the association between radiographic measures of reduction and functional and patient-reported outcomes 12 months following treatment.

    Interventions  Participants were randomized to receive volar locking plate, percutaneous pinning, or external fixation. Those who opted for nonoperative treatment received casts.

    Main Outcomes and Measures  Hand grip strength, wrist arc of motion, radial deviation, ulnar deviation, the Michigan Hand Outcomes Questionnaire (MHQ) total score, MHQ function score, and MHQ activities of daily living score were measured at 12 months following treatment.

    Results  Data from 166 WRIST participants (144 [86.7%] women; mean [SD] age, 70.9 [8.9] years) found that only 2 of the 84 correlation coefficients calculated were statistically significant. For patients aged 70 years or older, every degree increase in radial inclination away from normal (22°) grip strength in the injured hand was 1.1 kg weaker than the uninjured hand (95% CI, 0.38-1.76; P = .004) and each millimeter increase toward normal (0 mm) in ulnar variance was associated with a 10.4-point improvement in MHQ ADL score (95% CI, −16.84 to −3.86; P = .003). However, neither of these radiographic parameters appeared to be associated with MHQ total or function scores.

    Conclusions and Relevance  The study results suggest that precise restoration of wrist anatomy is not associated with better patient outcomes for older adults with DRF 12 months following treatment. Surgeons can consider this evidence to improve quality of care by prioritizing patient preferences and efficient use of resources over achieving exact realignment.

    Trial Registration  ClinicalTrials.gov identifier: NCT01589692

    Introduction

    Nearly 90 000 older adults in the United States experience distal radius fractures (DRFs) annually.1 Accounting for nearly 20% of all fractures seen by physicians, DRF is the second most common type of fracture experienced by older adults.2 The functional impairment and disability from DRF in older adults can be long-lasting, with substantial consequences on independent living.3 There is concern for increased fracture incidence and escalating treatment costs as the population of older individuals increases and becomes more susceptible to falls and DRF. In 2005, the annual cost of treating DRF in the population aged 65 years and older was approximately $500 million.4 By 2025, it is estimated that annual fracture incidence and treatment costs will rise by 20%.4

    Previous studies of DRF outcomes in persons who are aged 60 years and older report that precise anatomic reduction is not necessary to achieve satisfactory functional results because this population requires less functional recovery than younger patients.5-12 However, these conclusions cannot be applied to the current population of older adults who are much more active and functionally independent than previous generations.13-15 The perceived effect of disability from DRF will be more pronounced in the current population aged 60 years and older with greater demand in functional capacity. Studies have shown evidence that older adults place tremendous value on independent living, with reports of dependence making them feel as if they are a burden and delivering a toll on their emotional well-being.3,16,17 Some older adults even stated that they would accept increased mortality if it meant they would be functionally independent.18 Previous schools of thought on radiographic evaluation of reduction must be examined again with a more contemporary cohort of older patients.

    What adds to the necessity of a renewed investigation is that many of the prior studies that found no clinically relevant differences in outcomes based on radiographic measures lacked rigor in sample size and study design.19,20 A systematic review of studies that evaluated radiographic measures of reduction after DRF found no consistency in the types of fracture or severity of DRF included in study cohorts, definitions or methods of obtaining various radiographic measures, or the acceptability criteria for malalignment.21 The substantial variability in the current literature demonstrates a need for a study that strives to establish a model of measuring and using radiographic variables to assess outcomes after DRF.22,23

    In this study, we apply the rich and robust data collected from a large randomized clinical trial evaluating DRF treatment options to investigate the value of radiographic assessment in outcomes evaluation after DRF in older adults. Our results may help derive a definitive answer to the long-standing question of DRF management for contemporary populations of older adults and provide quality evidence for hand surgeons to tailor treatment plans to better fit patients’ needs. We hypothesized that radiographic measures of anatomic restoration are positively associated with both functional and patient-reported outcomes 12 months after DRF treatment for older adults.

    Methods
    Study Cohort

    We used data collected as part of the Wrist and Radius Injury Surgical Trial (WRIST), an international, 24-site randomized clinical trial of DRF treatment in older adults.24 At each participating site, 2190 patients aged 60 years or older were screened for eligibility from April 10, 2012, to December 31, 2016. Inclusion criteria were isolated DRFs (exception: concomitant ulnar styloid fracture) with displacement warranting surgical intervention (AO [Arbeitsgemeinschaft für Osteosynthesefragen (Association for the Study of Internal Fixation)] type A2, A3, C1, or C2 and meeting one of the following radiographic criteria after reduction attempt: dorsal tilt >10°, radial inclination <15°, or radial shortening >3 mm). All fractures were amenable to treatment with all 3 surgical options. Patients with open fractures, bilateral fractures, prior ipsilateral DRF, or additional serious trauma were ineligible. Also excluded were patients living in nursing homes or other assisted living facilities and those with neurologic conditions affecting upper extremity sensation or movement, comorbid conditions prohibiting surgery, serious neurologic or psychiatric conditions precluding informed consent, or inability to complete study questionnaires and follow directions. The trial protocol is available in Supplement 1. The parent study WRIST was approved by the institutional review board at the University of Michigan, which included secondary analyses of the data.

    Enrolled patients were randomized (after written consent was obtained) to receive percutaneous pinning, external fixation with or without supplemental k-wire fixation, or internal fixation with volar plate, stratified by study site. Those who consented to study participation but did not wish to undergo surgery despite the recommendation and who met identical eligibility criteria as randomized participants were treated with casting and were considered an observation group (eFigure 1 in Supplement 2). Follow-up care and rehabilitation and/or physical therapy were carried out per institutional standards at each site with 2 years of follow-up. For the present study, we included in our cohort the participants who completed 12-month functional evaluation, patient-reported outcomes questionnaires, and radiographic assessment.

    Variables of Interest

    In our study, we included 12-month measurements of the clinical parameters recommended as standard components of outcomes assessment by the Distal Radius Outcomes Consortium, such as bilateral hand grip strength, arc of motion, patient-reported disability and functional outcomes as assessed with the Michigan Hand Outcomes Questionnaire (MHQ), and alignment as measured on plain radiographs.25 All objective functional outcomes were measured by trained study coordinators at each participating site of the WRIST. Grip strength was measured with a hydraulic hand dynamometer set to the second rung.26 Arc of motion, radial deviation, and ulnar deviation were measured with a goniometer. Patient-reported outcome variables included MHQ total score, as well as MHQ function and activities of daily living (ADL) domain scores.27,28 For radiographic evaluation of reduction, alignment was measured on plain radiographs obtained at 12-month assessment. All radiographs were stored in Digital Imaging and Communications in Medicine format, and Picture Archive and Communicating System imaging software was used to view and measure the radiographic parameters. We included radial inclination, radial height, ulnar variation, and tilt (dorsal angles were recorded as negative: eg, dorsal 10° = −10°) because those were the parameters with high interrater and intrarater agreement.22 These variables were measured by 2 trained clinical staff members, based on definitions by the American Academy of Orthopaedic Surgeons.29 All radiographs were measured twice, and those with discrepancies of more than 10% were resolved by a third reading.

    Key clinical and demographic covariates included in our analysis model were sex, race, highest educational level, income, smoking status, preinjury level of activity, employment status 12 months following treatment, and status of dominant-hand injury. Race was self-reported by participants; this information was collected as required for all federally funded research projects. At enrollment, participants were asked to report their preinjury level of activity using the Rapid Assessment of Physical Activity, a 9-item questionnaire that evaluates a patient’s physical activity as sedentary, underactive, or active, based on guidelines from the Centers for Disease Control and Prevention.30

    Statistical Analysis

    Our analytic goal was to assess the association between 12-month posttreatment radiographic measures of reduction and patient outcomes. We divided the cohort into 2 groups based on median age (70 years) to clearly portray the association in each age cohort. In addition to the level of function and patient-reported outcomes in the injured hand, we calculated the difference in measurements and scores between the injured hand and uninjured hand (eg, difference in grip strength as uninjured hand minus injured hand) to capture within-person recovery of function and patient-reported outcomes. Higher positive values would indicate less recovery achieved. Among the 4 radiographic parameters, we excluded radial height from our model because it was highly correlated with radial inclination (r = 0.94) (eFigure 2 in Supplement 2).

    Based on the biomechanical principle of bony alignment, we hypothesized a U- or V-shaped association centered around the normal value for each radiographic parameter, at which point the difference in outcome between the injured and the uninjured hand is expected to be the smallest because we expected patients with perfect or near-perfect anatomic restoration to have better outcomes or greater recovery in function and MHQ scores than those with poor quality of reduction.29 This prognosis implies that the direction of association would differ for radiographic measures above and below the normal values; thus, we adopted a 2-phase multivariable regression model that permits separate regression coefficients above and below the normal values for each radiographic variable. We considered radial inclination of 22°, ulnar variance of 0 mm, and volar tilt of 11° as normal values, as defined by Taleisnik and Watson.31 Using the normal values as cutoffs, 2 slopes were calculated from the 2-phase multivariable regression model with all 3 radiographic variables included, adjusting for key covariates. For each radiographic variable, slope 1 assessed the association between the outcome Y and the values of the radiographic variable below or equal to the corresponding normal value adjusting for other radiographic values and covariates, and slope 2 examined the equivalent for values of the radiographic variable greater than the normal values. The regression equation for the 2-phase multivariable regression model is as follows:

    Y = βo + β1Xradinc + β2I(Xradinc >22) + β12(Xradinc × I[Xradinc >22])

    + γ1Xulnavar + γ2I(Xulnavar >0) + γ12{Xulnavar × I(Xulnavar >0)}

    + δ1Xtilt + δ2I(Xtilt >11) + δ12{Xtilt × I(Xtilt >11)}

    + ηTZcovariates,

    where

    β1 = slope 1 when radial inclination ≤22;

    β1 + β12 = slope 2 when radial inclination >22;

    γ1 = slope 1 when ulnar variance ≤0;

    γ1 + γ12 = slope 2 when ulnar variance >0;

    δ1 = slope 1 when tilt ≤11;

    δ1 + δ12 = slope 2 when tilt >11;

    and β12, γ12, and δ12 = Δslope, for each respective radiographic variable.

    Significantly different slopes (non-0 difference in slope [Δslope]) for each radiographic variable were considered consistent with the hypothesized association based on the biomechanical principle. We used a conservative level of α = .01 to be mindful of the multiple associations that we are assessing in our analysis. Statistical analyses were performed with R software version 3.5.3 (R Foundation).

    Results
    Sample Characteristics

    The final study cohort included 166 patients (144 [86.7%] women; mean [SD] age, 70.9 [8.9] years) from the parent WRIST study who completed all 3 components of 12-month assessment: function tests, patient-reported outcome questionnaires, and radiographs. We included 89 participants aged 60 to 69 years in the younger group and 77 participants age 70 years or older in the older group. Demographic and clinical characteristics were generally similar between the 2 subgroups for sex, race, educational level, preinjury Rapid Assessment of Physical Activity category, and status of dominant-hand injury (Table 1). However, a greater proportion of participants in the younger group had income greater than or equal to $50 000 (49.4% vs 28.6%; P = .05). Likewise, there were more full-time workers in the younger group (16 [18.0%] vs 1 [1.3%]) and more retired participants in the older group (68 [88.3%] vs 52 [58.4%]) (P < .001). Among clinical characteristics, there were 10 active smokers in the younger group (11.2%) compared with 0 active smokers in the older group (P = .003) (Table 1). For radiographic measures, the mean (SD) for radial inclination was similar between the younger (21.4° [6.1°]) and older (19.8° [6.4°]) groups (P = .10). For ulnar variance, the mean (SD) displacement was less in the younger group (2.1 [2.0] mm) than the older group (3.1 [2.7] mm) (P = .01). The distribution of tilt measurements was also different between the younger (0° [11.6°] mm) and older (−5.2° [12.7°] mm) groups (P < .01).

    Two-Phase Model Results

    Based on using a 2-phase multivariable regression model to describe the association between the radiographic measures of reduction and 12-month outcomes, we found that the Δslope was significant for only 3 models: (1) radial inclination vs difference in grip strength for the older group (Δslope = 1.00; 95% CI, 0.28-1.72; P = .01); (2) radial inclination vs difference in MHQ total score for the younger group (Δslope = −2.55; 95% CI, −4.45 to −0.64; P = .01); and (3) ulnar variance vs difference in MHQ ADL score for the older group (Δslope = 11.02; 95% CI, 4.57-17.47; P = .001) (Table 2).

    From the three 2-phase models with appropriate fit, we calculated slope 1 and slope 2 for each model separately. For the older group, we found that the difference in grip strength between the injured and uninjured hands increased by 1.1 kg for each 1° increase in radial inclination above 22° (slope 2; 95% CI, 0.38-1.76; P = .004). In other words, for every degree increase in radial inclination away from normal, the injured hand’s grip strength was 1.1 kg weaker than the uninjured hand (Table 3 and Figure, A). We found that in the younger group, each 1° increase in radial inclination less than or equal to 22° was associated with a 1.3-point increase in MHQ total score difference between the injured and uninjured hands (slope 1: 95% CI, 0.28-2.35; P = .02) (Table 4 and Figure, B). This result contradicted our hypothesized association, as it indicates that for the younger group, each degree increase in radial inclination toward normal was associated with poorer recovery measured via MHQ total score. In addition, for the older group, each 1-mm increase in ulnar variance was associated with a 10.4-point decrease in MHQ ADL score difference when ulnar variance less than or equal to 0 mm (slope 1: 95% CI, −16.84 to −3.86; P = .003) (Table 4 and Figure, C). The negative slope indicates that each millimeter increase in ulnar variance toward the normal value of 0 mm was associated with a 10.4-point greater improvement in MHQ ADL score for the injured hand compared with the uninjured hand. We found similar results in terms of the direction of association by using the absolute 12-month outcome measurements in the injured hand as the response variable instead of the difference in outcomes between the injured and uninjured hands.

    On finding only a few associations with statistical significance, we also checked to see if the results changed substantively when unadjusted for other radiographic parameters, that is, only 1 radiographic variable was included in the regression model instead of all 3 variables. The results were similar, with the same 3 statistically significant associations with the same direction of association (eTable 1 and eTable 2 in Supplement 2).

    Discussion

    In this study, we used data collected from an international, 24-site randomized clinical trial of DRF treatment options to investigate the value of precise anatomic restoration after DRF in older adults by examining the association between radiographic measures of reduction and outcomes 12 months following treatment. Our hypothesis was not confirmed; instead, radiographic measures were not associated with outcomes. In fact, only 3 of 14 models and 2 among 84 correlation coefficients were statistically significant. Furthermore, from the 3 regression models with appropriate fit, only 2 among 6 associations were congruent with the biomechanical principle of bony alignment: restoration of normal anatomic associations results in better function after DRF.29 Although we found that radial inclination greater than normal was associated with reduced grip strength relative to the uninjured hand and ulnar variance lower than normal was associated with lower MHQ score in adults aged 70 years and older, our results also indicate that these radiographic parameters were not associated with patients’ self-reported hand functional capacity (MHQ function scores) or overall hand health (MHQ total score). For adults aged 60 to 69 years, we found that radiographic measures of reduction did not appear to be associated with 12-month treatment outcomes.

    Evidence in the literature does not agree on the role of radiographic alignment in DRF management for older adults. Some studies conclude that there is limited utility in precise fracture reduction in older adults,5,6,10,11,19,32-38 whereas others have found that the quality of anatomic reduction influences patient outcomes.12,39-47 For example, Arora et al32 conducted a randomized study of 75 patients aged 65 years and older with DRF and found that volar locking plate fixation produced better restoration of normal anatomy on plain films compared with nonoperative treatment, but radiographic measures were not correlated with any improvement in functional outcomes. In contrast, Brogren et al46 examined the Disabilities of the Arm, Shoulder, and Hand questionnaire scores at various levels of radiographic displacement for 123 patients and found that patients with severe displacement had worse Disabilities of the Arm, Shoulder, and Hand scores at 2 years. Moreover, even among the studies that found a significant association between radiographic variables and treatment outcomes, there is no consensus on which parameters are the most important or the magnitude of influence.21 The heterogeneity of conclusions on the applicability and predictive potential of radiographic measures of reduction, as noted in several large Cochrane Database meta-analyses, is most likely a result of wide variability in study cohorts and design: the severity of fracture, outcomes reported and the way they were measured, and the way radiographic parameters were named and defined.48-50

    Limitations and Strengths

    There were some limitations to this study. Surgical technique, postoperative care, and therapy protocol care were not standardized in WRIST sites, and there may have been variations in care over the 24 participating sites and multiple surgeons. However, for our study, these differences increase the generalizability of our results by reflecting the variation in the real-world setting. The diversity in hospital settings and regional representation also adds to the robustness of the WRIST data. The parent WRIST study only included patients with substantially displaced DRF; thus, this is a limitation in our cohort selection. In addition, radiographic measurements on plain films are frequently shown to have low interrater and intrarater consistency. We minimized this bias by including only the radiographic parameters with a high rate of agreement,22 and discrepancies between the 2 sets of measurements were resolved with a third reading. We also measured radiographic variables according to the American Academy of Orthopaedic Surgeons’ definitions.29

    The strengths of this study outweigh the limitations. We diminished the risk of selection bias and confounding by using the data collected from a multicenter randomized clinical trial. We included in our analysis the outcome measures recommended by the Distal Radius Outcomes Consortium,25 which promotes a standardized, unified approach for DRF outcomes assessment. Our use of a 2-phase multivariable regression model also adds rigor to our study as it reflects the biomechanical principle of bony alignment of the wrist more appropriately than single-phase regression models.

    Conclusions

    The results of our study suggest that radiographic measures of reduction are not associated with functional outcomes and patient-reported outcomes in older adults after DRF treatment. Clinically, this finding implies that precise anatomic realignment of the wrist is not necessary for satisfactory outcomes. With this evidence, surgeons may elect to decrease operative time, use of resources, and associated costs that would have been spent to achieve perfect or near-perfect reduction. Decreasing time under anesthesia benefits patients as well with reduced risk of morbidity and mortality.51 In the treatment decision-making process, surgeons can prioritize patient preferences over the need to achieve exact realignment. Our study results may help to improve the quality of care in DRF management for older patients.

    Back to top
    Article Information

    Accepted for Publication: November 21, 2019.

    Published: January 17, 2020. doi:10.1001/jamanetworkopen.2019.19433

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Chung KC et al. JAMA Network Open.

    Corresponding Author: Kevin C. Chung, MD, MS, Department of Surgery, Michigan Medicine, 1500 E Medical Center Dr, TC 2130, Ann Arbor, MI 48109 (kecchung@med.umich.edu).

    Author Contributions: Drs Y. Kim and H. M. Kim had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Chung, Cho, H. M. Kim, Shauver.

    Acquisition, analysis, or interpretation of data: Cho, Y. Kim, H. M. Kim, Shauver.

    Drafting of the manuscript: Cho, Y. Kim, Shauver.

    Critical revision of the manuscript for important intellectual content: Chung, Cho, H. M. Kim, Shauver.

    Statistical analysis: Cho, Y. Kim, H. M. Kim.

    Obtained funding: Chung, Cho, Shauver.

    Administrative, technical, or material support: Shauver.

    Supervision: Chung, Cho, H. M. Kim.

    Conflict of Interest Disclosures: Dr Chung reported receiving funding from the National Institutes of Health and book royalties from Wolters Kluwer and Elsevier outside the submitted work. Ms Shauver reported receiving grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.

    Funding/Support: Funding for this study was provided by grant R01 AR062066 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Institute on Aging (Dr Chung) and by Clinical Research Grant Award 2827 from the American Foundation for Surgery of the Hand. Dr Cho received Surgical Scientist Training Grant in Health Services and Translational Research T32-GM008616-16A1 from the National Institutes of Health.

    Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Data Sharing Statement: See Supplement 3.

    Group Members: The WRIST Group members include the following: Michigan Medicine (Coordinating Center): Kevin C. Chung, MD, MS (principal investigator); H. Myra Kim, ScD (study biostatistician); Steven C. Haase, MD; Jeffrey N. Lawton, MD; John R. Lien, MD; Adeyiza O. Momoh, MD; Kagan Ozer, MD; Erika D. Sears, MD, MS; Jennifer F. Waljee, MD, MPH; Matthew S. Brown, MD; Hoyune E. Cho, MD; Brett F. Michelotti, MD; Sunitha Malay, MPH (study coordinator); Melissa J. Shauver, MPH (study coordinator). Beth Israel Deaconess Medical Center: Tamara D. Rozental, MD (coinvestigator); Paul T. Appleton, MD; Edward K. Rodriguez, MD, PhD; Laura N. Deschamps, DO; Lindsay Mattfolk, BA; Katiri Wagner. Brigham and Women’s Hospital: Philip Blazar, MD (coinvestigator); Brandon E. Earp, MD; W. Emerson Floyd; Dexter L. Louie, BS. Duke Health: Fraser J. Leversedge, MD (coinvestigator); Marc J. Richard, MD; David, S. Ruch, MD; Suzanne Finley, CRC; Cameron Howe, CRC; Maria Manson; Janna Whitfield, BS. Fraser Health Authority: Bertrand H. Perey, MD (coinvestigator); Kelly Apostle, MD, FRCSC; Dory Boyer, MD, FRCSC; Farhad Moola, MD, FRCSC; Trevor Stone, MD, FRCSC; Darius Viskontas, MD, FRCSC; Mauri Zomar, CCRP; Karyn Moon; Raely Moon. HealthPartners Institute for Education and Research: Loree K. Kalliainen, MD, MA (coinvestigator, now at University of North Carolina Health Care); Christina M. Ward, MD (coinvestigator); James W. Fletcher, MD; Cherrie A. Heinrich, MD; Katharine S. Pico, MD; Ashish Y. Mahajan, MD; Brian W. Hill, MD; Sandy Vang, BA. Johns Hopkins Medicine: Dawn M. Laporte, MD (coinvestigator); Erik A. Hasenboehler, MD; Scott D. Lifchez, MD; Greg M. Osgood, MD; Babar Shafiq, MD, MS; Jaimie T. Shores, MD; Vaishali Laljani. Kettering Health Network: H. Brent Bamberger, DO (coinvestigator); Timothy W. Harman, DO; David W. Martineau, MD; Carla Robinson, PA-C, MPAS; Brandi Palmer, MS, PC, CCRP. London Health Sciences Centre: Ruby Grewal, MD, MS (coinvestigator); Ken A. Faber, MD; Joy C. MacDermid, PhD (study epidemiologist); Kate Kelly, MSc, MPH; Katrina Munro; Joshua I. Vincent, PT, PhD. Massachusetts General Hospital: David Ring, MD, PhD (coinvestigator, now at University of Texas Health Austin); Jesse B. Jupiter, MD, MA; Abigail Finger, BA; Jillian S. Gruber, MD; Rajesh K. Reddy; Taylor M. Pong; Emily R. Thornton, BSc. Mayo Clinic: David G. Dennison, MD (coinvestigator); Sanjeev Kakar, MD; Marco Rizzo, MD; Alexander Y. Shin, MD; Tyson L. Scrabeck, CCRP. The MetroHealth System: Kyle Chepla, MD (coinvestigator); Kevin Malone, MD; Harry A. Hoyen, MD; Blaine Todd Bafus, MD; Roderick B. Jordan, MD; Bram Kaufman, MD; Ali Totonchil, MD; Dana R. Hromyak, BS, RRT; Lisa Humbert, RN. National University of Singapore: Sandeep Sebastin, MCh (coinvestigator), Sally Tay. Northwell Health: Kate W. Nellans, MD, MPH (coinvestigator); Sara L. Merwin, MPH. Norton Healthcare: Ethan W. Blackburn, MD (coinvestigator); Sandra J. Hanlin, APRN, NP-C; Barbara Patterson, BSN, CCRC. OrthoCarolina Research Institute: R. Glenn Gaston, MD (coinvestigator); R. Christopher Cadderdon, MD; Erika Gordon Gantt, MD; John S. Gaul, MD; Daniel R. Lewis, MD; Bryan J. Loeffler, MD; Lois K. Osier, MD; Paul C. Perlik, MD; W. Alan Ward, MD; Benjamin Connell, BA, CCRC; Pricilla Haug, BA, CCRC; Caleb Michalek, BS, CCRC. Pan Am Clinic/University of Manitoba: Tod A. Clark, MD, MSc, FRCSC (coinvestigator); Sheila McRae, MSc, PhD. University of Connecticut Health: Jennifer Moriatis Wolf, MD (coinvestigator, now at University of Chicago Medicine); Craig M. Rodner, MD; Katy Coyle, RN. University of Oklahoma Medicine: Thomas P. Lehman, MD, PT (coinvestigator); Yuri C. Lansinger, MD; Gavin D. O’Mahony, MD; Kathy Carl, BA, CCRP; Janet Wells. University of Pennsylvania Health System: David J. Bozentka, MD (coinvestigator); L. Scott Levin, MD; David P. Steinberg, MD; Annamarie D. Horan, PhD; Denise Knox, BS Kara Napolitano, BS. University of Pittsburgh Medical Center: John Fowler, MD (coinvestigator); Robert Goitz, MD; Cathy A. Naccarelli; Joelle Tighe. University of Rochester: Warren C. Hammert, MD, DDS (coinvestigator); Allison W. McIntyre, MPH; Krista L. Noble; Kaili Waldrick. University of Washington Medicine: Jeffery B. Friedrich, MD (coinvestigator); David Bowman; Angela Wilson. Wake Forest Baptist Health: Zhongyu Li, MD, PhD (coinvestigator); L. Andrew Koman, MD; Benjamin R. Graves, MD; Beth P. Smith, PhD; Debra Bullard.

    References
    1.
    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):2154-2162. doi:10.2106/JBJS.J.012802PubMedGoogle ScholarCrossref
    2.
    Levin  LS, Rozell  JC, Pulos  N.  Distal radius fractures in the elderly.  J Am Acad Orthop Surg. 2017;25(3):179-187. doi:10.5435/JAAOS-D-15-00676PubMedGoogle ScholarCrossref
    3.
    MacDermid  JC, Roth  JH, Richards  RS.  Pain and disability reported in the year following a distal radius fracture: a cohort study.  BMC Musculoskelet Disord. 2003;4:24. doi:10.1186/1471-2474-4-24PubMedGoogle ScholarCrossref
    4.
    Burge  R, Dawson-Hughes  B, Solomon  DH, Wong  JB, King  A, Tosteson  A.  Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025.  J Bone Miner Res. 2007;22(3):465-475. doi:10.1359/jbmr.061113PubMedGoogle ScholarCrossref
    5.
    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):237-242. doi:10.1097/BOT.0b013e31819b24e9PubMedGoogle ScholarCrossref
    6.
    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):1612-1620. doi:10.1007/s11999-008-0660-2PubMedGoogle ScholarCrossref
    7.
    Simic  PM, Weiland  AJ.  Fractures of the distal aspect of the radius: changes in treatment over the past two decades.  Instr Course Lect. 2003;52:185-195. doi:10.2106/00004623-200303000-00026PubMedGoogle Scholar
    8.
    Gehrmann  SV, Windolf  J, Kaufmann  RA.  Distal radius fracture management in elderly patients: a literature review.  J Hand Surg Am. 2008;33(3):421-429. doi:10.1016/j.jhsa.2007.12.016PubMedGoogle ScholarCrossref
    9.
    Beumer  A, McQueen  MM.  Fractures of the distal radius in low-demand elderly patients: closed reduction of no value in 53 of 60 wrists.  Acta Orthop Scand. 2003;74(1):98-100. doi:10.1080/00016470310013743PubMedGoogle ScholarCrossref
    10.
    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. doi:10.1053/jhsu.2000.jhsu025a0019PubMedGoogle ScholarCrossref
    11.
    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):1121-1127. doi:10.1016/j.jhsa.2004.07.002PubMedGoogle ScholarCrossref
    12.
    McQueen  M, Caspers  J.  Colles fracture: does the anatomical result affect the final function?  J Bone Joint Surg Br. 1988;70(4):649-651. doi:10.1302/0301-620X.70B4.3403617PubMedGoogle ScholarCrossref
    13.
    Medicare Enrollment Dashboard Data File. Centers for Medicare & Medicaid Services. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMSProgramStatistics/Dashboard.html. Accessed December 28, 2018.
    14.
    Manton  KG, Gu  X, Lamb  VL.  Change in chronic disability from 1982 to 2004/2005 as measured by long-term changes in function and health in the US elderly population.  Proc Natl Acad Sci U S A. 2006;103(48):18374-18379. doi:10.1073/pnas.0608483103PubMedGoogle ScholarCrossref
    15.
    Toosi  M, Torpey  E. Older workers: Labor force trends and career options. United States Department of Labor Bureau of Labor Statistics website. https://www.bls.gov/careeroutlook/2017/article/older-workers.htm. Accessed March 18, 2019.
    16.
    Morris  NS.  Distal radius fracture in adults: self-reported physical functioning, role functioning, and meaning of injury.  Orthop Nurs. 2000;19(4):37-48. doi:10.1097/00006416-200019040-00008PubMedGoogle ScholarCrossref
    17.
    Bialocerkowski  AE.  Difficulties associated with wrist disorders—a qualitative study.  Clin Rehabil. 2002;16(4):429-440. doi:10.1191/0269215502cr516oaPubMedGoogle ScholarCrossref
    18.
    Fried  TR, Bradley  EH, Towle  VR, Allore  H.  Understanding the treatment preferences of seriously ill patients.  N Engl J Med. 2002;346(14):1061-1066. doi:10.1056/NEJMsa012528PubMedGoogle ScholarCrossref
    19.
    Grewal  R, MacDermid  JC.  The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients.  J Hand Surg Am. 2007;32(7):962-970. doi:10.1016/j.jhsa.2007.05.009PubMedGoogle ScholarCrossref
    20.
    Grewal  R, MacDermid  JC, Pope  J, Chesworth  BM.  Baseline predictors of pain and disability one year following extra-articular distal radius fractures.  Hand (N Y). 2007;2(3):104-111. doi:10.1007/s11552-007-9030-xPubMedGoogle ScholarCrossref
    21.
    Lalone  EA, Grewal  R, King  GJ, MacDermid  JC.  A structured review addressing the use of radiographic measures of alignment and the definition of acceptability in patients with distal radius fractures.  Hand (N Y). 2015;10(4):621-638. doi:10.1007/s11552-015-9772-9PubMedGoogle ScholarCrossref
    22.
    Kreder  HJ, Hanel  DP, McKee  M, Jupiter  J, McGillivary  G, Swiontkowski  MF.  X-ray film measurements for healed distal radius fractures.  J Hand Surg Am. 1996;21(1):31-39. doi:10.1016/S0363-5023(96)80151-1PubMedGoogle ScholarCrossref
    23.
    Macdermid  JC, Richards  RS, Donner  A, Bellamy  N, Roth  JH, Hildebrand  KA.  Reliability of hand fellows’ measurements and classifications from radiographs of distal radius fractures.  Can J Plast Surg. 2001;9(2):51-58. doi:10.1177/229255030100900204Google ScholarCrossref
    24.
    Chung  KC, Malay  S, Shauver  MJ, Kim  HM; WRIST Group.  Assessment of distal radius fracture complications among adults 60 years or older: a secondary analysis of the WRIST randomized clinical trial.  JAMA Netw Open. 2019;2(1):e187053-e187053. doi:10.1001/jamanetworkopen.2018.7053PubMedGoogle ScholarCrossref
    25.
    Waljee  JF, Ladd  A, MacDermid  JC, Rozental  TD, Wolfe  SW; Distal Radius Outcomes Consortium.  A unified approach to outcomes assessment for distal radius fractures.  J Hand Surg Am. 2016;41(4):565-573. doi:10.1016/j.jhsa.2016.02.001PubMedGoogle ScholarCrossref
    26.
    Trampisch  US, Franke  J, Jedamzik  N, Hinrichs  T, Platen  P.  Optimal Jamar dynamometer handle position to assess maximal isometric hand grip strength in epidemiological studies.  J Hand Surg Am. 2012;37(11):2368-2373. doi:10.1016/j.jhsa.2012.08.014PubMedGoogle ScholarCrossref
    27.
    Chung  KC, Pillsbury  MS, Walters  MR, Hayward  RA.  Reliability and validity testing of the Michigan Hand Outcomes Questionnaire.  J Hand Surg Am. 1998;23(4):575-587. doi:10.1016/S0363-5023(98)80042-7PubMedGoogle ScholarCrossref
    28.
    Kotsis  SV, Lau  FH, Chung  KC.  Responsiveness of the Michigan Hand Outcomes Questionnaire and physical measurements in outcome studies of distal radius fracture treatment.  J Hand Surg Am. 2007;32(1):84-90. doi:10.1016/j.jhsa.2006.10.003PubMedGoogle ScholarCrossref
    29.
    Graham  TJ.  Surgical correction of malunited fractures of the distal radius.  J Am Acad Orthop Surg. 1997;5(5):270-281. doi:10.5435/00124635-199709000-00005PubMedGoogle ScholarCrossref
    30.
    Topolski  TD, LoGerfo  J, Patrick  DL, Williams  B, Walwick  J, Patrick  MB.  The Rapid Assessment of Physical Activity (RAPA) among older adults.  Prev Chronic Dis. 2006;3(4):A118.PubMedGoogle Scholar
    31.
    Taleisnik  J, Watson  HK.  Midcarpal instability caused by malunited fractures of the distal radius.  J Hand Surg Am. 1984;9(3):350-357. doi:10.1016/S0363-5023(84)80222-1PubMedGoogle ScholarCrossref
    32.
    Arora  R, Lutz  M, Deml  C, Krappinger  D, Haug  L, Gabl  M.  A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older.  J Bone Joint Surg Am. 2011;93(23):2146-2153. doi:10.2106/JBJS.J.01597PubMedGoogle ScholarCrossref
    33.
    Chen  Y, Chen  X, Li  Z, Yan  H, Zhou  F, Gao  W.  Safety and efficacy of operative versus nonsurgical management of distal radius fractures in elderly patients: a systematic review and meta-analysis.  J Hand Surg Am. 2016;41(3):404-413. doi:10.1016/j.jhsa.2015.12.008PubMedGoogle ScholarCrossref
    34.
    Egol  KA, Walsh  M, Romo-Cardoso  S, Dorsky  S, Paksima  N.  Distal radial fractures in the elderly: operative compared with nonoperative treatment.  J Bone Joint Surg Am. 2010;92(9):1851-1857. doi:10.2106/JBJS.I.00968PubMedGoogle ScholarCrossref
    35.
    Mellstrand Navarro  C, Ahrengart  L, Törnqvist  H, Ponzer  S.  Volar locking plate or external fixation with optional addition of k-wires for dorsally displaced distal radius fractures: a randomized controlled study.  J Orthop Trauma. 2016;30(4):217-224. doi:10.1097/BOT.0000000000000519PubMedGoogle ScholarCrossref
    36.
    Williksen  JH, Frihagen  F, Hellund  JC, Kvernmo  HD, Husby  T.  Volar locking plates versus external fixation and adjuvant pin fixation in unstable distal radius fractures: a randomized, controlled study.  J Hand Surg Am. 2013;38(8):1469-1476. doi:10.1016/j.jhsa.2013.04.039PubMedGoogle ScholarCrossref
    37.
    Karantana  A, Downing  ND, Forward  DP,  et al.  Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial.  J Bone Joint Surg Am. 2013;95(19):1737-1744. doi:10.2106/JBJS.L.00232PubMedGoogle ScholarCrossref
    38.
    Plant  CE, Parsons  NR, Costa  ML.  Do radiological and functional outcomes correlate for fractures of the distal radius?  Bone Joint J. 2017;99-B(3):376-382. doi:10.1302/0301-620X.99B3.35819PubMedGoogle ScholarCrossref
    39.
    Symonette  CJ, MacDermid  JC, Grewal  R.  Radiographic thresholds with increased odds of a poor outcome following distal radius fractures in patients over 65 years old.  JHSGO. 2019;1(2):65-69. doi:10.1016/j.jhsg.2019.02.002Google Scholar
    40.
    Martinez-Mendez  D, Lizaur-Utrilla  A, de-Juan-Herrero  J.  Intra-articular distal radius fractures in elderly patients: a randomized prospective study of casting versus volar plating.  J Hand Surg Eur Vol. 2018;43(2):142-147. doi:10.1177/1753193417727139PubMedGoogle ScholarCrossref
    41.
    Batra  S, Gupta  A.  The effect of fracture-related factors on the functional outcome at 1 year in distal radius fractures.  Injury. 2002;33(6):499-502. doi:10.1016/S0020-1383(01)00174-7PubMedGoogle ScholarCrossref
    42.
    Leung  F, Ozkan  M, Chow  SP.  Conservative treatment of intra-articular fractures of the distal radius—factors affecting functional outcome.  Hand Surg. 2000;5(2):145-153. doi:10.1142/S0218810400000338PubMedGoogle ScholarCrossref
    43.
    Karnezis  IA, Panagiotopoulos  E, Tyllianakis  M, Megas  P, Lambiris  E.  Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius.  Injury. 2005;36(12):1435-1439. doi:10.1016/j.injury.2005.09.005PubMedGoogle ScholarCrossref
    44.
    Kodama  N, Takemura  Y, Ueba  H, Imai  S, Matsusue  Y.  Acceptable parameters for alignment of distal radius fracture with conservative treatment in elderly patients.  J Orthop Sci. 2014;19(2):292-297. doi:10.1007/s00776-013-0514-yPubMedGoogle ScholarCrossref
    45.
    Gartland  JJ  Jr, Werley  CW.  Evaluation of healed Colles’ fractures.  J Bone Joint Surg Am. 1951;33-A(4):895-907. doi:10.2106/00004623-195133040-00009PubMedGoogle ScholarCrossref
    46.
    Brogren  E, Wagner  P, Petranek  M, Atroshi  I.  Distal radius malunion increases risk of persistent disability 2 years after fracture: a prospective cohort study.  Clin Orthop Relat Res. 2013;471(5):1691-1697. doi:10.1007/s11999-012-2767-8PubMedGoogle ScholarCrossref
    47.
    Aro  HT, Koivunen  T.  Minor axial shortening of the radius affects outcome of Colles’ fracture treatment.  J Hand Surg Am. 1991;16(3):392-398. doi:10.1016/0363-5023(91)90003-TPubMedGoogle ScholarCrossref
    48.
    Handoll  HH, Huntley  JS, Madhok  R.  External fixation versus conservative treatment for distal radial fractures in adults.  Cochrane Database Syst Rev. 2007;(3):CD006194. doi:10.1002/14651858.CD006194.pub2PubMedGoogle Scholar
    49.
    Handoll  HH, Madhok  R.  Surgical interventions for treating distal radial fractures in adults.  Cochrane Database Syst Rev. 2001;(3):CD003209. doi:10.1002/14651858.CD003209PubMedGoogle Scholar
    50.
    Handoll  HH, Vaghela  MV, Madhok  R.  Percutaneous pinning for treating distal radial fractures in adults.  Cochrane Database Syst Rev. 2007;(3):CD006080. doi:10.1002/14651858.CD006080.pub2PubMedGoogle Scholar
    51.
    Gordon  NA, Koch  ME.  Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surgery: a review of 1200 consecutive cases.  Arch Facial Plast Surg. 2006;8(1):47-53. doi:10.1001/archfaci.8.1.47PubMedGoogle ScholarCrossref
    ×