The Times Are A Changing With Today's SeniorsThe authors of this study start out by saying, Approximately 10 per cent of 65 year-old white women in the United States will sustain a distal radial fracture during the remainder of their lifetime. A distal radial fracture is a wrist fracture. Ouch! That seems like a lot. And with the aging Baby Boomers now part of that statistic, that could be you, not your mother. So, now that they have our attention, what's the message?
Treatment for this problem seems to be changing. The authors review Medicare data for two separate time periods (1996-1997 and 1998-2005) to find out how this condition is being treated and by whom. They used the Medicare records to count up how many patients in this age group had open (surgery) versus closed (casting) treatment, type of surgery, and type of medical specialist treating the patient.
With new treatment available now like the locking plate system to stabilize fractures, treatment can be more aggressive. But does it need to be? Does a more invasive, but potentially more stabilizing treatment improve function or speed up recovery? Do the benefits of surgery outweigh the cost? If not, then a study of the Medicare population like this can help guide patients, concerned family members, and physicians evaluating the cases.
Sample data of patient information is collected routinely from Medicare Part B records by the Dartmouth Institute for Health Policy and Practice. The dataset is made available to other researchers like the authors of this study at the University of Michigan in Ann Arbor upon request for research purposes. Medicare Part B is especially useful because it includes patients ages 65 to 99, gender, race, diagnosis, and information on claims for fee-for-service patients. Age brackets are further broken down into groups less than 70 years old, 70 to 74, 75 to 79, 80 to 84, and 85 and older.
There are also number codes to show what kind of doctor treated the patient (orthopedic surgeon, hand surgeon, family practice, emergency medicine) and to explain what services the physicians provided. Code numbers are given to each medical procedure so it is possible to use the codes to see how many people had what kind of surgery. The overall treatment options included: 1) closed treatment (cast or other immobilization), 2) percutaneous (through the skin) pinning, 3) internal fixation (plates, screws, pins, wires inside the arm), or 4) external fixation (screws placed through the bones with connecting rods outside the body).
Here are a few key findings from this study. First, closed treatment was the most common way to treat a wrist fracture (specifically fracture of the radius bone, one of the two bones in the forearm). The use of external fixation was very low throughout the study period. But over time, there was a definite trend as surgeons started using internal fixation more and closed treatment less. Towards the end of the study, the use of cutaneous pin fixation started to go down, too.
Most of the differences in what type of surgery was done seem to be based on the surgeon's specialty. For example, hand surgeons were more likely to do open surgery; orthopedic surgeons were more likely to use closed reduction (set the bone and cast it without surgery). The hand surgeons were four times more likely to use internal fixation than the orthopedic surgeons. Treatment didn't differ based on gender (male versus female) or based on race but age did seem to make a difference. Older patients were less likely to have surgery and more likely to be immobilized.
The biggest surprise was the number of people treated for distal radial fractures by nonsurgeons, such as the primary care (family) doc or a physician in the emergency department. Of course, none of these medical doctors performed surgery, so all of those patients (about 10 per cent of the total number in the study) were treated with closed reduction (immobilization).
There is come concern about treating older adults with closed reduction. It doesn't realign the bones if they are separated or misaligned. The senior heals (if at all) with what's called a malunion. This can result in stiffness, loss of motion, and decreased functional use of that hand. That's why when the new volar locking plating system came on the market in 2000, more surgeons took advantage of this technique to get a better fracture healing and function in this age group. Volar just refers to the side of the arm the plates are put in (palmer side rather than the back of the hand/wrist side).
The plating system is a contoured stainless steel implant that looks like a wrench with multiple holes in the rounded top end and all the way down the stem. It is used when there are complex fractures with multiple bone fragments. The system is laid flat against the bone. Screws can be placed in any of the holes where extra stability is needed.
The implant can be slipped under the skin and placed where it's needed, so it's an internal fixation device that doesn't require wide open incision and dissection of all the soft tissues. Studies done so far show the plating system speeds up recovery and reduces the amount of time immobilized. But the present study had no way to compare results, so whether or not this treatment approach is better must be determined by other researchers.
The authors predict that future treatment of distal radial fractures in Medicare-aged patients will continue to shift toward more aggressive approaches as active seniors ask for treatment that won't slow them down too much. Many of the methods previously used only in younger patients (e.g., internal fixation) will be used in older adults. And more innovative surgical approaches will be designed to take care of this age group efficiently yet safely.
Kevin C. Chung, MD, MS, et al. Trends in the United States in the Treatment of Distal Radial Fractures in the Elderly. In Journal of Bone and Joint Surgery. August 2009. Vol. 91-A. No. 8. Pp.1868-1873.
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