Adequately Reduced Distal Radial Fractures in Elderly Patients: How Long Should We Immobilize?

Commentary Distal radial fractures are the most common upper-extremity fractures, and their incidence is rising. For most fracture patterns, the current evidence has suggested similar functional outcomes with operative and nonoperative treatment in the elderly population1. Although the injury is common, the optimal duration for immobilization after an acceptable reduction is unclear. This duration is likely a trade-off between pain and risk of redisplacement when too brief and loss of function and of independence when too lengthy. Sala-Pujals et al. challenged the traditional recommendations for cast immobilization up to 6 weeks for adequately reduced distal radial fractures in elderly patients. The authors included 135 patients ≥65 years of age with adequately reduced distal radial fractures, with 68 patients randomized to receive 4 weeks of casting and 67 patients randomized to receive 6 weeks of casting. Importantly, the study was adequately powered to detect minimally clinically importance differences in their primary outcome, the 10-cm visual analog scale (VAS) pain score, as well as their secondary outcomes, the Patient-Rated Wrist Evaluation (PRWE) and the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). The authors found no differences in any outcome at 10 days after cast removal, 3 months, 6 months, or 1 year. Their findings suggest that a 4-week immobilization duration is safe for these fractures in elderly patients. This study adds to a growing body of recent literature asking whether we can get away with shorter immobilization times in the closed treatment of acceptably aligned distal radial fractures. Some prior randomized controlled trials have studied nondisplaced or minimally displaced fractures2,3, whereas others have studied fractures requiring closed reduction3,4. Previous studies have assessed a shorter immobilization time ranging from 4 weeks to as brief as 1 week2–4. No previous study has found a clinically important detrimental outcome with shorter immobilization. There are a number of unique factors about this study that make it interesting and impactful. First, the authors focused on distal radial fractures in patients ≥65 years of age. This line of inquiry about whether shorter immobilization is safe and effective is particularly germane in the elderly patient population. These patients are most vulnerable to feeling a loss of independence after an injury and after prolonged immobilization. Furthermore, the risk of secondary displacement with shorter immobilization carries less weight in the elderly population, because we know that there is a wider range of radiographic parameters within which older patients have acceptable function5. Second, the authors’ inclusion of displaced distal radial fractures, rather than only nondisplaced or minimally displaced fractures, selects for potentially unstable fracture patterns and strengthens their ultimate conclusions. Third, the study was appropriately powered to assess short-term pain levels and 1-year functional outcomes, both salient in their own way. The decision on how long to immobilize still depends on sound clinical judgment tailored to the individual patient. The authors reported that 1 patient in the 4-week immobilization group developed a nonunion at 12 months, a rare complication of closed management of distal radial fractures. Nonetheless, the authors should be commended for a well-designed, well-executed randomized controlled trial that makes a compelling case that 4 weeks of cast immobilization is sufficient for most distal radial fractures in elderly patients.