Distal Radius Fracture in an Active Septuagenarian
A 72-year-old right-hand-dominant retired teacher falls onto her right wrist. She is independent, drives, gardens, and plays bridge weekly. Radiographs show a dorsally angulated distal radius fracture with 20 degrees of dorsal tilt, 3 mm of radial shortening, and intra-articular extension with a 2 mm step-off. The ulnar styloid is fractured at its base. She has osteopenia on prior DXA. She lives alone and has no family nearby to help with self-care. She asks whether she needs surgery or whether a cast is enough.
1. How do the fracture characteristics and her functional demands influence the operative versus nonoperative decision?
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Key unfavorable features: dorsal tilt of 20° (normal volar tilt ~11°), 3 mm radial shortening, and an intra-articular step-off of 2 mm. These predict post-traumatic arthritis and loss of wrist flexion/extension and grip if left malunited. Her demands - driving, gardening, bridge (fine motor and sustained wrist positioning) - require a functional, pain-free arc of motion and grip strength.
Nonoperative casting can be considered for minimally displaced, extra-articular fractures in low-demand patients. Here, the combination of intra-articular step-off, dorsal tilt, and shortening in a cognitively intact, active patient favors operative fixation to restore articular congruity and length. Osteopenia affects fixation strategy (screw purchase, need for augmented fixation or spanning) but is not by itself a contraindication.
The judgment call is that age alone should not drive nonoperative care; function and fracture displacement should. Given her activity level and the articular step-off, surgical fixation is the more defensible recommendation, with the caveat that her social isolation affects postoperative logistics.
2. What fixation strategy would you choose and why, and how do you address her living situation?
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Volar locking plate fixation is the workhorse for a dorsally displaced, intra-articular fracture in an osteopenic patient: it provides angular-stable support, allows early motion, and addresses dorsal tilt and shortening. Considerations:
- Intra-articular step-off: direct or indirect reduction with fluoroscopic confirmation; consider a small dorsal approach or arthroscopy if the step-off cannot be reduced percutaneously.
- Osteopenia: use longer screws, consider cement augmentation or a plate with multiple distal locking options; avoid over-long screws penetrating dorsally.
- Ulnar styloid base fracture: usually does not require fixation unless there is distal radioulnar joint instability.
- Alternative: external fixation or fragment-specific fixation if comminution precludes plate fixation.
Social plan: because she lives alone, arrange a preoperative conversation about home safety, a short skilled-nursing or rehabilitation stay, home health, and transportation for follow-up. Early mobilization with hand therapy is important. Document the plan and her agreement.
3. What are the most likely complications to discuss, and how does osteopenia change your consent conversation?
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Complications to discuss: loss of reduction or hardware failure (higher with osteopenia), tendon irritation or rupture (flexor pollicis longus from prominent distal screws), median nerve neuropathy (carpal tunnel symptoms are common after distal radius fractures), post-traumatic arthritis from residual articular step-off, complex regional pain syndrome, and stiffness.
Osteopenia changes the consent in two ways: (1) it increases the risk of screw pull-out, loss of fixation, and the need for revision or supplemental fixation; (2) it may favor a strategy that protects fixation during healing, such as a period of immobilization or a spanning construct. The patient should understand that bone quality affects durability of the repair, not just the surgery itself. Emphasize that hand therapy and monitoring for nerve symptoms are part of the recovery, and that her solitary living situation means she should have a plan for help before surgery.