Lithuanian University of Health Sciences

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1 Lithuanian University of Health Sciences

MEDICAL ACADEMY FACULTY OF MEDICINE

Evgeny Usher

Evaluation of radiological markers of patients with distal radius fractures older than 60 years old amongst conservative and surgical volar locking plate treatment

In the department of Orthopedics and Traumatology

Submitted in partial fulfillment of the requirements for the degree of Master of Medicine

Scientific supervisor:

Dr. Liudas Bazaras, Orthopedic surgeon

June 2017 Kaunas

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SUMMARY

Master thesis by Evgeny Usher.

Title- Evaluation of radiological markers of patients with distal radius fractures older than 60 years old amongst conservative and surgical volar locking plate treatment.

The aim of the theses- To investigate radiological markers according criteria of Lafontaine, AAOS and Dutch national Guidelines in patients older than 60 years with distal radius fracture that underwent conservative casting immobilization or surgical volar locking plate in LUHS Kaunas clinics.

Objectives of the study-1.To determine whether radiological markers of Lafontaine, AAOS and Dutch national guidelines criteria are sufficient for choosing conservative or surgical approach. 2. To evaluate risk for secondary dislocation according Lafontaine criteria between conservative and surgery groups. 3. To evaluate the short term radiological outcomes according Dutch national guideline for conservative and surgical treatment. 4. To determine if different types of fractures (according AO/OTA classification) have an effect on treatment.

Methodology- The study is a retrospective analysis of radiological records of 74 patients older than 60 years with distal radius fracture. The patients were divided into 2 groups (37 patients in each group) according to treatment with surgical volar locking plate approach or conservative with cast immobilization. Radiological images were analyzed according to Lafontaine criteria for secondary dislocation risk, AAOS recommendations for surgical approach and Dutch national guideline for conservative approach for markers of: ulnar variance, radial length, radial inclination, volar tilt/dorsal angulation, AO/OTA classification of the fracture, ulnar fracture, dorsal cortex fragmentation and step-off. Results- In the conservative group 10 out of 37 patients (27%) did not meet the Dutch guideline criteria for good reposition, but adding Lafontaine criteria for the assessment, all 37 met indication for cast. In the surgical group 14 out of 37 patients (38%) did not meet criteria for operation, but in adding Lafontaine criteria a total of 30 patients (81%) had indication for surgery. No significant difference was seen in short term radiological results between the treatments. All A type fracture were in conservative group, and all C type fractures were in surgical group (p= 0.001). Prevalence of females with fractures was higher.

Conclusions- 1. Lafontaine, AAOS and Dutch national guidelines are sufficient for selection of conservative or surgical treatment. 2. Risk for secondary dislocation before and after reposition is higher in surgical group. 3. There is no difference in short term radiological outcomes between surgical volar locking plate and conservative management with cast immobilization. 4. A type and C type fractures according AO/OTA classification can affect choice of treatment in patients older than 60 years.

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CONFLICT OF INTEREST

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LIST OF ABBREVIATIONS

DRF- distal radius fracture AP- anteroposterior

CT- computed tomography

AO/OTA- Arbeitsgemeinschaft für Osteosynthesefragen /Orthopedic Trauma Association AAOS- American Academy of Orthopedic Surgeons

BMD- Bone mineral density

LUHS- Lithuanian University of health and science RF- Risk factor

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INTRODUCTION

Distal radius fractures (DRF) are very common injuries, and their incidence, particularly in females, increases with age. They are caused by 2 main mechanisms- high energy trauma or low energy trauma, and the most common way is a fall on an extended hand [1]. Majority of the injuries in individuals older than 60 years are caused by a fall from a standing position primarily in patients with osteoporotic bone [2].

Despite the high frequency of injury, there is no specific guideline or consent on appropriate treatment for these fractures, especially in the elderly. Treatment options for these patients divided into two main categories: immobilization with cast or operative volar locking plate [7].

The choice to whether operate or go with conservative treatment relies upon which management will result in better outcome. To help achieve the appropriate decision several guidelines were created advising which criteria of radiological markers of patients are suitable to each treatment option. Lafontaine criteria for fracture instability [23], AAOS recommendations for surgical approach [25] and Dutch national guideline for conservative approach [26] are assessed in this research. The mentioned guidelines were chosen according to the recommendation of Orthopedics and Traumatology department in LUHS Kaunas hospital.

Assessment of those guidelines is done on radiological films of patients from Lithuanian university of health and science (LUHS) Kaunas clinics to evaluate their usage, and determine if they are helpful enough to reach a decision regarding treatment.

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THE AIM AND OBJECTIVES

The aim of the thesis is to investigate radiological markers according criteria of Lafontaine, AAOS and Dutch national Guidelines in patients older than 60 years with distal radius fracture that underwent conservative casting immobilization or surgical volar locking plate in LUHS Kaunas clinics.

Objectives of the study:

1. To determine whether radiological markers of Lafontaine, AAOS and Dutch national guidelines criteria are sufficient for choosing conservative or surgical approach.

2. To evaluate risk for secondary dislocation according Lafontaine criteria between conservative and surgery groups.

3. To evaluate the short term radiological outcomes according Dutch national guideline for conservative and surgical treatment.

4. To determine if different types of fractures (according AO/OTA classification) have an effect on treatment.

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LITERATURE REVIEW

Distal radius fractures (DRF) are very common this days, and their incidence, especially in females, raises with age. They are one of the most common fractures seen in the emergency department, accounts for approximately 20% of fractures in the elderly population [1]. DRF are caused by high energy trauma due to a fall from height or vehicular accident, or low energy trauma such as a fall from a standing height, and the most common way is a fall on an extended hand.

Majority of the injuries in individuals older than 60 years old are caused by a fall from a standing position and primarily in persons with osteoporotic bone [2].

Osteoporosis is a disease of decrease bone mineral density (BMD) and imbalance in the architecture of the bone leading to increased bone fragility and fracture risk. Prevalence of osteoporosis is 4 times greater in women than in men [3]. Brogren et al [4] and Flinkkila et al [5] compared the frequency of DRF between men and women and found that women have 5 times more chances of fractures than men, and incidence doubles every 10 years from the age of 50. A different study also found that there is a relation between osteoporosis and the severity of DRF. In the research Clayton et al [6] shows that the lower BMD is, the more severe intra-articular fractures are. Also the study suggests that a decrease in BMD is related to increase in secondary dislocation after closed reduction with 1.5 times more in the osteoporosis group compared to normal group.

Choosing the appropriate treatment in osteoporotic bone fracture is complicated and debatable.

The burden of osteoporosis fracture incidents will continue rising in the next decades because of aging of the elderly population.

Despite the high frequency of injury, there is no definitive guideline and consent on appropriate treatment for these fractures, especially in the elderly. Treatment of DRF is divided into two main options: immobilization with cast or operative fixation. Most of the fractures can be treated non- surgically with a cast, but operative treatment has increased in the last years and now it is one of the most commonly performed orthopedic procedures. This can be attributed to the improved imaging techniques, development of better operative techniques, and better outcomes in individuals. Yet many questions about best treatment option in older than 60 years of age are still under deliberation, because the radiological findings in elderly patients do not always correlate with the functional outcome [7].

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10 For correct choice of treatment there are different important markers that are taken into consideration. The force of trauma, age, position of the hand during the impact, bone quality, characteristics of fracture such as: location, type of fracture, association with adjacent tissues and other relevant anatomy [8]. Assessment of the markers is done by radiological imaging, most widely used is x-ray that is usually sufficient for analysis of the fracture and selection of treatment, but for more complicated fractures with higher comminution computed tomography (CT) is also used [9].

Radiographic anatomy

For assessment of DRF radiographic imaging is performed in 2 planes, anteroposterior (AP) and lateral views. In AP view 4 markers are used [10, 11] (figure 1):

1) Radial inclination- determined as the angle between two lines - one perpendicular to the longitudinal axis of the radius and the second line between the styloid tip of radius and the ulnar aspect of the distal radius (average: 22o_-23o_{) .}

2) Radial length- determined as the distance between the tip of the radial styloid and the distal articular surface of the ulna head (average: 11 mm-12 mm).

3) Ulnar variance- calculated as the difference in lengths between the ulna and the distal articular surfaces of the radius. It can be neutral, positive or negative with average (-1) - (+1) mm.

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11 Fig. 1. A, Radial inclination. B, Radial length. C, Ulnar variance. D, step-off.

In lateral view one marker is used (figure 2):

Volar tilt - defined as the angle between the perpendicular line to the longitudinal axis of the radius and a line along the radial articular surface (average is 11o). A negative volar tilt is referred to as dorsal angulation [12].

Fig. 2. Volar tilt.

Type of fracture

Classification of DRF developed over time to an extended system characterizing multiple features of the fracture based on mechanism or anatomy. Common systems include the Frykman, Melone, Mayo, Fernandez and the AO/OTA system [13]. No system was proven to be better than the other but widely preferred classification by surgeons is the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen /Orthopedic Trauma Association) system [14]. In this review the emphasis is on the AO/OTA system classification.

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12 A type – extra-articular fractures of the radius

B type – partial intra-articular fractures of the radius C type – complete intra-articular fractures of the radius.

Fig. 3. AO classification for radius fracture

Reliability of radiographic measurements

When interpreting radiographic images of DRF, accuracy of the measures and errors from the investigated markers needs to be taken into account when applying it for the therapy. Because no definite way to calculate this markers exist it is not known if the same standard approach for calculations are always being used or if the interpretations are correct [16]. Watson et al found in their research that error margins in the values for palmar tilt, ulnar variance, radial length and radial inclination appears to be insignificant enough for the measurements to be useful in influencing the choice of treatment. Also they suggested that when the values of the measurements are under 1 mm they are difficult to measure, and palmar tilt, ulnar variance and radial inclination can still be useful in that case but intra- articular step-off is unreliable, and better accuracy will be through CT imaging [17].

Management of distal radius fractures

The decision to whether operate or go with conservative treatment relies upon which management will result in better outcome [18]. Many factors are responsible for the choice, mainly the age, radiographic markers and type of fracture. Some studies suggest that operative treatment has advantages with improved outcomes [19] whereas other studies like Nellans et al [20] and Mattila et al [21] suggests that there is no evident difference in functional outcome in follow up after one year between the treatments. Yet even though there is not much evidence about better results with surgery, over the years the number of operations has increased [22].

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13 Because there is no specific guideline to choose the correct treatment, every surgeon calculates anatomical parameters of the fracture with somewhat different results and can decide the right path according to each specific case. Still some well-designed studies have formed a guide for treatment.

A guide for instability of radius fracture was done by Lafontaine et al. They analyzed the risk factors (RF) for secondary dislocation and found that they all have effect on the radiological outcome. They concluded that patients with < 3 factors have less risk for secondary dislocation, and if there is > 3 factors it is considered as high risk for secondary dislocation. The factors are: dorsal angulation > 20°; dorsal cortex fragmentation; intraarticular distal radius fracture; ulnar fracture; and age over 60 years [23].

Important factor that can highly influence the choice of treatment is C type fracture according to the AO/OTA system. The C type fracture is a very big risk for instability and high dislocation percentage, even if primary reduction was successful. According to Bartl et al 41% of all patients >65 years old with C type fracture that underwent cast immobilization were sent to surgery due to secondary dislocation after two weeks of primary treatment [24]. Another classification was done by the American academy of orthopedic surgeons (AAOS) that published a guideline of recommendations on the treatment of distal radius fractures [25]. They suggest that operative fixation for DRF is needed after primary reposition when: post-reduction radial shortening is >3mm, dorsal angulation >10o, or step-off >2mm. The recommendation was classified as moderate strength, this means that the benefits are higher than they are harmful. For conservative management a guide by Dutch national guideline was constructed [26]. According to the study acceptable healing and good primary reposition is satisfactory for conservative treatment with cast immobilization when: radial shortening of <5 mm, radial inclination is >15 degrees, between 15o dorsal angulation and 20o volar tilt, and articular step-off is < 2mm.

Complications of distal radius fracture treatment

Many complications were found to occur after both operative and non-operative treatments like malunion, infection, tendon complications and complex regional pain syndrome [27, 28, 29, 30].

Complication rate increases with age, severity of fracture and poor economic status [31]. A malunion is the most common complication, and conservative treatment is the most common cause of this

complication [32]. A study comparing the outcomes and complications of DRF between volar locking plate and cast immobilization, found that 35% of the patients treated conservatively developed a malunion. Patients treated with volar plate fixation, however, had no such complication [33]. Different problems associated with malunion are decrease range of motion, pain, and deformities [34]. Volar locking plate is replacing other techniques like dorsal plate fixation and external fixation because of

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14 decreased incidents of complication. [35, 36, 37]. Treating the fracture with a volar locking plate provides bigger area for fixation and the concave surface protects from irritation [38]. With volar plate fixation the period of immobilization is shorter and allowing earlier return to previous activity level [33]. Tarallo et al. concluded in his research that this should be the preferred technique when correcting extra-articular distal radius fracture malunions, especially in elderly patients with poor bone quality [39].

In the literature a large difference is shown in the rate of infection between external fixation and volar plating. It is reported that the rate of infection is 11 % in patients treated with external fixation, compared to 0.8% in surgical volar plate [40]. Another common complication is associated with tendon. Surgical treatment after DRF can result in both flexor and extensor tendon complications. Volar locking plate approach was developed as an alternative approach to dorsal plate and external fixation to avoid the complication [41]

In order to achieve the best outcome early immobilization and early treatment needs to be performed. Therefore 2 methods of treatment are addressed in this research, conservative and volar locking plate approaches. The recommendations from the guidelines mentioned in this article are not absolute and individual alterations in what is considered a normal anatomy must be taken into consideration. No definitive answers are concluded in the literature about the best treatment in elderly patients, because there is not enough evidence as to whether surgical or non-surgical treatment is better with regards to radiological and functional outcomes in the short and long-term. Some studies even say that the functional outcome with bad radiological markers compared to those with preferable radiographic marker is the same [42].

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RESEARCH METHODOLOGY AND METHODS

Subjects

This study is a retrospective analysis of radiological records of 74 patients over the age of 60 with distal radius fractures between January 2013 and August 2016 in orthopedics department in Lithuanian University of Health and Science (LUHS) Kaunas clinics. The patients were divided into 2 groups according to the method of treatment. 37 patients were treated conservatively with cast immobilization (34 females and 3 males, mean age 72 + 8.18) and 37 patients treated with surgical volar locking plate approach (34 females and 3 males, mean age 70.9 +7.08).

Study population

Between January 2013 and August 2016, 505 patients older than 60 years were admitted and treated for DRF both in conservative and surgical methods (external fixation, volar locking plate, k-wire, dorsal plate). After exclusion of patients, 74 patients were included in this study.

Radiological analysis

For each patient data was collected in 3 x-ray control images all in anteroposterior and lateral views: before reposition, after reposition and an x-ray control after surgery and 3 weeks after cast immobilization. Every image was analyzed for radiological markers of: ulnar variance, radial length, radial inclination, volar tilt/dorsal angulation, AO/OTA classification of the fracture, ulnar fracture, dorsal cortex fragmentation and step-off. Assessment of data from the images was done according to Lafontaine criteria for fracture instability [23], AAOS recommendations for surgical approach [25] and Dutch national guideline for conservative approach [26].

Inclusion criteria

1. Patients 60 years and older

2. All surgical operations included one type of surgery (volar locking plate) 3. All conservative treatments included cast immobilization

4. Three follow up x-ray images 5. Ulnar fractures

6. A, B and C type of fracture (AO/OTA classification). Exclusion criteria

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16 2. Poor x-ray image follow-up

3. External fixation of distal radius fractures 4. K- Wires

5. Dorsal plate

6. Other fractures of the affected extremity.

Statistical analysis

Statistical analysis was performed by using the Statistical Package for Social Sciences, version 24 for Windows (SPSS 24). The normality assumption of data was verified with the Kolmogorov-Smirnov test. The Student’s t-test was used for testing the hypotheses about equality of the means for normally distributed data. For not normally distributed data, we used non parametric Mann-Whitney test. Data were presented as mean ( ) ± standard deviation (SD). For testing hypothesis about independence, the Chi-square test was used. The difference between groups was considered as statistically significant when p<0.05.

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RESULTS

In this study 74 patients were assessed, out of which 37 patients treated conservatively with cast immobilization, and 37 patients were treated with surgical approach using volar locking plate.

The first test analyzed the risk of secondary dislocation for both groups before reposition. According Lafontaine guidelines >3 criteria considered as positive risk, in conservative group 4 patients (11%) met criteria, in surgery group 23 patients (62%) met the criteria, table 1. There was a significantly greater number of patients in surgical group as compared to conservative group (*p=0.01). Surgery group patients have higher risk for dislocation before reposition compared to conservative group.

Table 1. Secondary dislocation risk before reposition

Type Secondary dislocation risk factors (RF) Total

< 3 RF > 3 RF * Conservative 33 (89%) 4 (11%) 37 patients 100% Surgery 14 (38%) 23 (62%) 37 patients 100%

Dislocation risk after reposition was also assessed for both groups. The results show that reposition improved radiological markers, in conservative group no patient was at risk for dislocation anymore, and in surgery 15 (41%) patients were still at risk, table 2. There was a significantly greater number of patients in surgical group as compared to conservative group (*p=0.01). Surgery group patients have higher risk for dislocation after reposition compared to conservative group.

Table 2. Secondary dislocation risk after reposition

Type Secondary dislocation risk factors Total

< 3 RF > 3 RF * Conservative 37 (100%) 0 0.0% 37 patients 100% Surgery 22 (59%) 15 41% 37 patients 100%

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73%

27%

4 criteria

< 3criteria

Next analysis was looking for how many patients from total 37 of conservative group were holding the criteria for good reposition to be suitable for cast immobilization according to the Dutch national guideline (4/4= good reposition). 27 patients met criteria (73%) and 10 patients (27%) did not meet the criteria, table 3.

Table 3. Criteria for good reposition and cast immobilization

Group Criteria for good reposition Total

< 3 criteria 4 criteria

Conservative 10 27 37 patients

10 patients that did not meet criteria had A type fracture (8 patients) and B type fracture (2 patients). None of them had risk for secondary dislocation after reposition, table 4.

Table 4. Patients that did not met criteria for good reposition

Type of fracture Dislocation risk

A type B type

Not met criteria (n=10) 8 2 0

Next analysis was evaluating the results of patients from surgery group. To be suitable for surgery at least one criteria needs to be met. 23 patients (62%) met criteria for operative fixation, 14 patients (38%) did not meet criteria, table 5.

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19 Table 5. Criteria for surgery

Group Criteria for surgery Total

0 criteria > 1 criteria

Surgery 14 23 37 patients

14 patients that did not meet criteria were evaluated for type of fracture and secondary dislocation risk in table 6.

Table 6. Patients who did not meet criteria for surgery Patients Dislocation risk + C

type fracture

Only C type fracture Neither

n= 14 7 4 3

There was a significant difference in treatment selection according the guidelines with higher number of patients that met the criteria of the 3 guidelines and those that did not, table 7.

Table 7. Evaluation of guidelines effectiveness in selection of treatment

Treatment selection According 3 guidelines Did not meet any of guidelines Surgery * (p=0.011) 30 patients (81%) 7 patients (19%) Conservative * (p=0.006) 37 patients (100%) 0 patients (0%)

38%

62%

0 criteria

>1 criteria

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20 All 74 patients were analyzed for assessment of radiological outcome and results were considered to be a good outcome when they met the criteria for good reposition (4/4 criteria), table 8. There was no statistical significance between the type of treatment compared to good reposition outcomes, p = 0.635.

Table 8. Good outcome

Type Good outcome Total

< 3 criteria 4 criteria Conservative 19 51% 18 49% 37 patients Surgery 16 43% 21 57% 37 patients

There was significant difference in radiological markers in surgery group compared to conservative group, with better results in the surgical group, table 9.

Table 9. Characteristics of radiological markers of DRF after surgery/ 3 weeks after casting Characteristics Conservative group Surgery group P value Volar tilt (degrees)

mean ± SD (range) 0.74 + 11.7 ((-22) - 22) 8.02 + 8.7 ((-22) - 23) 0.06

Radial inclination (degrees) mean ± SD (range) 16.35 + 4.35 (10 - 28) 19 + 5.7 (9 - 32) 0.024 Radial length (mm) mean ± SD (range) 7.7 + 2.4 (4 - 16) 9.4 + 2.9 (4.1 - 15.3) 0.012 Ulnar variance (mm) mean ± SD (range) 1.2 + 3.4 ((-6) - 10) -1.08 + 2.9 ((-5) - 6) 0.06

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21 All A type fracture were in conservative group, and all C type fractures were in surgery group.

B type fracture divided into: 11patients (46%) in conservative group, 13 patients (54%) in surgery group, table 10. There was a significantly higher number of patients with A type fracture in conservative group compared to surgery group, and significantly higher number of patients with C type fracture in surgery group compared to conservative group (*p = 0.001).

Table 10. Type of fracture

Treatment Type of fracture

A type * B type C type *

Conservative (n=37) 22 (100%) 15 (53.6%) 0 (0.0%)

Surgery (n=37) 0 (0.0%) 13 (46.4%) 24 (100%)

Results of prevalence of gender between the patients, graph 1. Graph1. Gender

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DISCUSSION

In order to decide what the correct treatment for DRF is, 3 recommended guidelines for radiological markers analysis were checked in this research on 74 patients in LUHS Kaunas clinics. The aim of this thesis was to investigate the radiological markers from those guidelines in order to determine if they are sufficient for selection of appropriate treatment.

First results- risk for secondary dislocation of the fracture (Lafontaine criteria) before reposition was examined for surgery (62% of patients had risk) and conservative (11% of patients had risk) groups. There was a statistical significance between the type of treatment and the dislocation risk before reposition, p=0.01. After reposition was done, the same markers were tested again and no patient was at risk for dislocation from conservative group and 15 patients had risk in surgery group (p=0.01). Surgery group patients have higher risk for dislocation before and after reposition compared to conservative group. According to the Dutch national guideline in conservative group 27 patients (73%) met criteria and they had cast immobilization. 10 patients (27%) did not meet criteria for good reposition but had no risk for secondary dislocation according Lafontaine guideline, and further analysis on them also showed that 8 of them had A type fracture and 2 had B type fracture. In combination of the 2 guidelines between all 37 patients the results show that all of them had indications for conservative approach and in this group of treatment the guidelines were sufficient enough to help determine the treatment.

In addition, according the AO foundation, A type and B type fractures that are not/or minimally displaced like in these patients, require conservative approach, supporting the outcome from the guidelines to go for cast immobilization [43].

Next analysis was evaluating the results of patients from surgery group. Using the criteria for surgery (according AAOS) and Lafontaine a total of 30 patients (81%) met criteria for operative fixation and were suitable for surgery. Among the 7 patients that did not meet the criteria, 4 patients had only C type fracture, and according AO foundation [43] all C type fractures that are displaced need surgical approach. The other 3 patients that did not qualify for any indication above is attributed to other factors that were not examined in this research, could be personal aspects, surgeon preference or other.

As presented before, C type fracture is a very big risk for instability and high dislocation percentage [24]. Zaręba et al found that surgical operation leads to minimal redisplacements comparing to closed reduction and cast immobilization. Also the type of fracture has high influence on further changes of radiological markers. According to his research C type fracture leads to greater redisplacement than A type fractures

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23 [44]. In addition, other sources show that secondary displacement is significantly associated with patient age. It is suggests that when examining the association of secondary displacement with patient age, initial displacement degree, and dorsal comminution, only patient’s age was significantly associated with late secondary displacement compared to the non-displacement group [45].

Another studies says that malunion can results from combination of bad cast application, decrease in soft tissue swelling, fracture comminution or mechanical forces spanning the radiocarpal joint, making the non-operative treatment at greater risk for dislocation, so surgery is a good option to avoid anticipated dislocation [46[.

In conclusion, using the guidelines is sufficient enough for selection of treatment, there was a statistical significance in treatment selection according the guidelines between the patients that met the criteria of the 3 guidelines and those that did not.

Other findings in this research were focused on the radiographic outcomes after treatments. In the literature DRF are thought to be stable when the fracture alignment is preserved with minor displacement after a time of cast immobilization for 1–2 weeks [47]. Early secondary displacement (until 2 weeks) are more common than late secondary displacement (more than two weeks) [45].

Therefore in our research conservative group was evaluated after 3 weeks with cast immobilization, and surgery group was evaluated with x-ray control after surgery to compare to the radiographic outcomes to the criteria of good reposition. Final results show that in short term results there is no statistical significance between the ways of treatment and radiographic outcomes according the good reposition criteria (p=0.635). Yet in our opinion surgical group had more preferable outcomes because risk for secondary dislocation was higher and more complex type of fractures (C type) were treated. Studies say that volar locking plate has better short term radiological results. Different researchers found [48,49,50] that post operatively, volar locking plate showed good to excellent radiological outcomes in most of the cases compared to conservative approach. The achieved reduction that is found in the early period is also maintained throughout the follow up duration much better. Yet most of the data available does not include routine evaluation of the radiological markers. Information about radiographic correlation with outcome is still incomplete, no definitive answers concluded in the literature to the best treatment in elderly patients, and there is not enough evidence as to whether surgical or non-surgical treatment is better [42, 51].

In regards to the range of radiological markers value, when taking into consideration the mean of each parameter [10, 11, 12], there was a statistical significance between surgical and conservative group.

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24 Surgical group showed tendency to more preferable radiological outcome than conservative group in regards to general population mean values.

Lastly, other characteristics were assessed in the patients, type of fracture and gender.

There was a statistical significance between the treatment and type of fracture (p <0.05). All A type fractures were in conservative group, and all C type fractures were in surgery group. B type fractures divided into: 11 patients (46%) in conservative group, 13 patients (54%) in surgery group.

The results show that diagnosed A type and C type fractures have a more predictable pathway of treatment, but with B type it is not possible to say the way of management and radiological markers will help to guide to a more precise decision.

In regards to gender, in our study we found big difference between females and males prevalence of DRF (91.9% compared to 8.1% respectively). It could be attributed to osteoporosis [3, 4, 5] or other factors that influence the high rate of fractures.

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CONCLUSIONS

1. Lafontaine, AAOS and Dutch national guidelines are sufficient for selection of conservative or surgical treatment.

2. Before and after reposition risk for secondary dislocation was higher in surgery group.

3. There was no difference in short term radiological outcomes between surgical volar locking plate and conservative management with cast immobilization.

4. A type and C type fractures according AO/OTA classification can affect choice of treatment in patients older than 60 years.

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RECOMMENDATIONS

1. We recommend to use the mentioned guidelines for choosing correct treatment approach. The guidelines cover the radiological parameters that are helpful to make a decision.

2. Despite the results of no difference in short term radiological outcome between the 2 treatment groups, patients older than 60 years old who are found to have secondary dislocation risk and patient who have more complicated type of fracture (AO- C type), we recommend to use surgical volar locking plate approach.

3. We recommend to perform a wider study about the treatment choice for DRF that includes radiological parameters together with additional factors that can influence the decision of treatment (such as patient’s status, comorbidities, and medications).

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LITERATURE LIST

1) Mohammad A , Mohammad J, Mohammad H, and Mohammad D.

Evaluation of instability factors in distal radius fractures. J Res Med Sci 2013 Oct; 18(10): 892–896. 2) Kate W. Nellans, MD, MPH1, E Kowalski, BS2, and K C. Chung, MD, MS, The Epidemiology of Distal Radius Fractures. Hand Clin 2012 May ; 28(2): 113–125.

3) E. Hernlund & A. Svedbom & M. Ivergård & J. Compston & C. Cooper & J. Stenmark & E. V. McCloskey & B. Jönsson &J. A. Kanis, Osteoporosis in the European Union: medical management, epidemiology and economic burden. Arch Osteoporos 2013 8:136

4) Brogren E*1, Petranek M2 and Atroshi I, Incidence and characteristics of distal radius fractures in a southern Swedish region. BMC Musculoskeletal Disorders2007, 1471-2474-8-48

5) Flinkkilä T , Sirniö K, Hippi M, Hartonen S, Ruuhela R, Ohtonen P, Hyvönen P, Leppilahti J.

Epidemiology and seasonal variation of distal radius fractures in Oulu, Finland. Osteoporos Int 2011 Aug; 22(8):2307-12.

6) Clayton RA , Gaston MS, Ralston SH, CourtBrown CM, McQueen MM. Association between decreased bone mineral density and severity of distal radial fractures. J Bone Joint Surg Am 2009 Mar 1;91(3):6139

7) Arora R , Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing non operative 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 Dec 7;93(23):214653

8) JC. BellotiI, J Baptista Gomes dos SantosI, V. Ynoe de MoraesII, F. Vitiello WinkIII, M. Jun Sugawara TIV, Flávio FaloppaV. The IDEAL classification system: a new method for classifying fractures of the distal extremity of the radius – description and reproducibility. Sao Paulo Med. J.

2013; 131(4):252-6

9) Meena S, Sharma P, Abhishek Kumar Sambharia, and Dawar A. Fractures of Distal Radius: An Overview. J Family Med Prim Care. 2014 Oct ; 3(4): 325–332.

10) R. Arora, MD1, M. Gabl, MD1, S. Erhart, MD1, G. Schmidle, MD1, C. Dallapozza, MD1, and M. Lutz, MD1. Aspects of Current Management of Distal Radius Fractures in the Elderly Individuals. Geriatr Orthop Surg Rehabil. 2011 2(5-6) 187-194

11) Michael P. O’Malley & Craig Rodner & Andrew Ritting & Mark P. Cote & Robin Leger & Harlan Stock & Jennifer M. Wolf, Radiographic interpretation of distal radius fractures: visual estimations versus digital measuring techniques, (2014) 9:488–493

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28 12) Megan E. Mignemi, MD, Ian R. Byram, MD, Carmen C. Wolfe, BS, Kang-Hsien Fan, MS, Elizabeth A. Koehler, MS, John J. Block, MD, Martin I. Jordanov, MD, Jeffry T. Watson, MD, Douglas R. Weikert, MD, and Donald H. Lee, MD. Radiographic Outcomes of Volar Locked Plating for Distal Radius

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