In the present study, we reviewed over 2,000 citations from three large databases in order to evaluate the functional outcomes, radiographic parameters, and complications of the five most common treatment methods for unstable DRFs in the elderly. Our systematic review revealed that motion after each treatment option was statistically different, when measured at least 12 months following injury. Functional range of wrist flexion and extension for ADLs, however, were 54° and 60° respectively. 31
Therefore, wrist motion was clinically comparable because the final motions (regardless of the treatment method) were between 116° and 133°. DASH scores were also significantly different among the four treatment groups except PKF, but not clinically different because the difference was only 2.5 or less out of 100 points. There were significant differences in some radiographic parameters, namely volar tilt and ulnar variance. Specifically, treatment with VLPS or Non-BrEF resulted in significantly better volar tilt and ulnar variance when compared to treatment with CI. This was not unexpected, because it is well known that fractures treated conservatively are prone to collapse.11, 12
VLPS prevents this by using fixed-angle screws to hold the fragment in place, whereas Non-BrEF can directly support the distal fragments through pins, which are secured to the device. It is also well known that wrist function is not related to wrist deformity in elderly patients, lending credence to our finding that there were no clinically significant functional differences amongst the 5 treatment methods, as measured by the DASH and motion despite the significant differences in radiographic parameters.15, 16, 32
Recent randomized controlled studies of unstable DRFs, not restricted to the elderly, demonstrated that both wrist function and DASH scores in groups treated with VLPS were comparable with those treated with BrEF, radial column plate, and PKF one year after surgery.33, 34
VLPS, however, leads to better wrist motion and DASH score in the first 6 to 12 weeks after surgery. We found that the period of immobilization, which allowed patients limited or no wrist movement, and the types and rates of complications were also different amongst the five strategies in the present review. The rate of recovery and limitations of ADL during treatment affect the quality of life of patients with DRFs. Compared to younger patients, the elderly already experience a delay of approximate 6-month in gaining functional improvement.24
These findings imply that rate of recovery of ADL performance and the possibility of major complications during recovery may be more important factors than the final functional outcome when deciding which treatment strategy is best for elderly patients with DRFs. A decision analysis, which compares the utility of, or preference for, each treatment option from the perspective of elderly individuals themselves, may serve as a reference for decision-making based on risk-benefit ratio that the elderly population places on each intervention.
Our results were limited by the strength of available evidence. Heterogeneity exists amongst the five groups in many characteristics, including indications of surgery, manipulation of redisplaced fractures and fracture type. Most notably, there are significant differences in the proportions of intra-articular fractures amongst the groups, although we were unable to determine the influence of these confounding factors on outcomes at final follow-up because of insufficient information on patients’ loss to follow-up. On the other hand, it remains controversial whether experiencing an intra-articular fracture, or the subsequent osteoarthritis of the radiocarpal joint that frequently occurs following this type of fracture, greatly affects long-term function of the wrist.13, 35–37
In future research, it would be prudent to distinguish between outcomes of extra-articular and intra-articular fractures, including coronal split fracture or Barton’s fracture, which generally require management with open reduction and internal fixation.32, 38
Another limitation of our primary data analysis is that the primary literature search inclusion criteria required only a mean age of 60 for each study’s patient sample, not that all the patients in each series be over the age of 60. We did this because we also included a minimum follow-up period of 12 months, limiting our results to only 21 citations. However, to serve as an internal test of validly, we redid our literature search and analysis with more stringent criteria to isolate journal articles with study populations comprised completely of elderly patients. Even with the addition of a third database, this reduced the number of citations in our secondary literature search to 8. This greatly impacted our ability to analyze and compare important aspects of DRF outcomes such as motion, standardized functional scores and complications. In comparing radiographic outcomes, the results between the analyses of the primary and secondary literature searches were similar () in showing that operative management is superior to CI in maintaining volar tilt and preventing radial shortening. We feel that this similarity between the analyses of our two literature searches adds validity to the assumptions we made in broadening our search to studies with a mean age of 60 or older in our original inclusion/exclusion criteria. Thus, we are confident in using our primary literature search analysis in the description of the variability between the 5 treatment options in regards to motion, DASH score and complications.
Another limitation is that 10 retrospective case series were included in this systematic review. A systematic review of randomized controlled trials or cohort study is ranked as a higher level of evidence. However, the importance of systematic review relies on the methodological search for the underlying causes of heterogeneity, which allows the authors to make evidence-based recommendations for future investigations. 39
Therefore, the present analysis uses all available evidence in the literature to yield the pooled data for comparative purposes to propose necessary follow-up studies.
Even with the inclusion of these retrospective case series, the mean SEQES score was 25.6, out of 48, reflecting our stringent inclusion criteria for 12-month follow-up, complications, and functional and radiologic assessments. Although the SEQES is a subjective measure of quality, it does lend some merit to the studies included and also draws attention to some flaws in our literature. Blinding treatment providers and patients remains a difficult issue to address in the field of surgical outcomes research, but others seem much easier to improve. Only 9% of studies had established that they had sufficient power to detect treatment effects, and 41% had independent evaluators assess function or radiologic outcomes. This study reflects inadequacies in our current literature that can only be attended to if they are acknowledged going forward.
There remains no consensus regarding the appropriate treatment for unstable DRFs in elderly patients. Consequently, indications for surgical intervention are judged individually based on the balance of risk and benefit. If there is no great difference between functional outcomes and ADL one year after injury, factors that affect quality of life during recovery such as pain, the rate of recovery, limitation of ADLs, and potential complications will be more critical in deciding the treatment strategy. Quality of life depends on individuals’ activities, lifestyles and preferences, rather than age. Nevertheless, it seems age, as well as geography, influence the selection of treatment methods for DRF.9, 40
The use of internal fixation is on the rise, yet there have been no large-scale randomized controlled trials to compare VLPS to other treatments in elderly patients. Although there is some evidence that outcomes of VLPS are as good in elderly patients as those in young patients,24
there is no proof that these outcomes justify this more invasive, and likely more expensive, procedure. The definite answer regarding the optimal management of the growing incidence of DRFs in the elderly demands the conduct of multicenter clinical trials to better define the best practice in treating this prevalent injury.