Management of Distal Radius Fractures in Frail Elderly Patients With High Anesthetic Risk: Cast Immobilization Versus Volar Locking Plate Fixation

Abstract

Background

Distal radius fractures are common among elderly patients and frequently pose management challenges due to advanced age, multiple comorbidities, and increased anesthesia-related risks. In high-risk individuals with limited physiological reserve, the choice between surgical and nonoperative treatment remains controversial. This study aimed to compare the functional, radiological, and complication outcomes of volar locking plate fixation and cast immobilization in elderly patients with distal radius fractures and high anesthetic risk.

Methods

This retrospective, single-center comparative study included patients aged ≥65 years with acute distal radius fractures and an American Society of Anesthesiologists (ASA) class ≥III, treated either with cast immobilization or volar locking plate fixation between January 2022 and December 2023. Functional outcomes were assessed using the Patient-Rated Wrist Evaluation (PRWE), Visual Analog Scale (VAS), grip strength, and Activities of Daily Living (ADL) at 6 and 12 months. Radiological parameters, including radial height, radial inclination, volar tilt, and ulnar variance, were evaluated using standardized digital measurements. Treatment-related complications were recorded and analyzed. Statistical analyses included independent-samples t-tests, chi-square tests, and effect size calculations, with a p-value <0.05 considered statistically significant.

Results

A total of 60 patients (30 treated with cast immobilization and 30 treated with volar locking plate fixation) met the inclusion criteria and were included in the final analysis. No statistically significant differences were observed between the two groups in terms of Patient-Rated Wrist Evaluation (PRWE) scores, Visual Analog Scale (VAS) scores, grip strength, or independence in activities of daily living at either 6 or 12 months of follow-up (all p > 0.05). Radiological parameters were largely comparable between groups at final follow-up; however, volar tilt and ulnar variance demonstrated significantly more favorable values in the volar locking plate group. The overall complication rates were similar between treatment modalities. Malunion and complex regional pain syndrome were observed in both groups, with higher—but not statistically significant—rates in the cast immobilization group. No major complications, including deep infection, tendon rupture, neurovascular injury, implant failure, or reoperation, were encountered during follow-up.

Conclusion

In elderly high-risk patients with distal radius fractures, volar locking plate fixation provides functional and radiological outcomes comparable to those of cast immobilization. Despite the surgical nature of plate fixation, it did not demonstrate a clear functional advantage over conservative management in this frail population. Given its truly nonoperative character and low complication profile, cast immobilization remains a safe and practical first-line treatment option for elderly patients in whom surgical intervention carries substantial risk.

Keywords

distal radius fracture elderly patients volar locking plate cast immobilization high-risk patients

İntroduction

Distal radius fractures (DRFs) are among the most common skeletal injuries in the elderly population.¹ With advancing age, age-related osteoporosis, declining bone quality, and increasing medical frailty may complicate treatment strategies in elderly patients with distal radius fractures.² In younger or medically fit patients, surgical fixation techniques—particularly volar locking plate (VLP) fixation—have been shown to provide more reliable anatomical reduction and facilitate earlier functional recovery.³ However, in elderly patients with significant comorbidities and limited physiological reserve (e.g., American Society of Anesthesiologists [ASA] class III or higher), surgical intervention may be associated with increased perioperative morbidity, and the optimal treatment strategy remains controversial.⁴

Numerous studies have compared surgical fixation, most commonly VLP fixation, with conservative cast immobilization in elderly patients with distal radius fractures, yet the available evidence remains inconclusive. A recent meta-analysis reported that surgical treatment may improve medium-term DASH scores and grip strength but does not significantly reduce overall complication rates when compared with nonoperative management.⁵ Moreover, several studies have suggested that residual deformities following conservative treatment do not necessarily compromise long-term functional outcomes in low-demand elderly patients, as moderate anatomical imperfections may be clinically tolerated in this population.⁶ However, many of these studies have excluded frail individuals with severe systemic comorbidities or high anesthetic risk, thereby limiting the generalizability of their findings to this particularly vulnerable subgroup.Consistent with these findings, a randomized controlled trial by Hassellund et al demonstrated that cast immobilization was non-inferior to volar locking plate fixation in patients aged 65 years and older at one-year follow-up.⁷

Elderly patients with substantial medical comorbidities represent a clinically important yet underrepresented population in the existing literature. In these high-risk individuals, treatment decisions must carefully balance the potential functional benefits of surgical fixation against the risks associated with anesthesia and surgical stress. While volar locking plate fixation is widely accepted as a standard surgical option for unstable distal radius fractures, its advantages over cast immobilization in frail elderly patients with limited physiological reserve remain insufficiently defined.

Therefore, in this retrospective comparative study, we aimed to evaluate and compare the functional, radiological, and complication outcomes of volar locking plate fixation and cast immobilization in elderly patients with distal radius fractures and high anesthetic risk (ASA class ≥III). We hypothesized that volar plate fixation would not provide a clear long-term functional or radiological advantage over cast immobilization in this high-risk population. By specifically focusing on a frail cohort often excluded from randomized controlled trials, this study seeks to provide clinically relevant evidence to inform treatment decision-making in elderly patients for whom the balance between surgical benefit and overall medical risk is particularly critical.

Materials and Methods

Study Design and Ethical Approval

This retrospective, single-center study was conducted in the Orthopaedics and Traumatology Department between January 2022 and December 2023. The study was performed in accordance with the ethical standards of the institutional research committee and the principles of the 1964 Declaration of Helsinki and its later amendments. Ethical approval was obtained from the Institutional Ethics Committee. Due to the retrospective nature of the study, the requirement for informed consent was waived, and all patient data were anonymized prior to analysis.

Patient Selection

Patients aged 65 years and older who sustained an acute distal radius fracture and were treated with either cast immobilization or volar locking plate fixation were evaluated. Hospital electronic records were screened to identify all patients treated for distal radius fractures during the study period, and only those meeting the predefined age, anesthetic risk, treatment, and follow-up criteria were considered eligible for inclusion.

Inclusion Criteria

1. Age ≥65 years,

2. Radiographically confirmed acute distal radius fracture,

3. Presence of significant medical comorbidities or American Society of Anesthesiologists (ASA) class ≥III that precluded open reduction and internal fixation under general or regional anesthesia,

4. Initial treatment with below-elbow cast immobilization or volar locking plate fixation,

5. Minimum 12 months of follow-up,

6. Availability of complete clinical and radiographic data.

Exclusion Criteria

1. Pathological or periprosthetic fractures,

2. Open fractures classified as Gustilo–Anderson type II or higher,

3. Ipsilateral upper extremity fracture or previous wrist surgery,

4. Neurological or rheumatologic disorders affecting wrist function,

5. Highly comminuted intra-articular fractures (AO type C3) or fractures requiring emergency open reduction.

Recorded demographic data included age, sex, fracture side (right/left), and hand dominance. In addition, major systemic comorbidities were recorded based on patients’ medical histories and preoperative anesthesiology assessments.

Fracture patterns were classified according to the AO/OTA classification system based on initial radiographs. Most included fractures resulted from low-energy mechanisms and were extra-articular or simple intra-articular patterns (AO type A2–A3 and C1). Highly comminuted intra-articular fractures (AO type C3) and fractures requiring emergency open reduction were excluded during the screening process.

Treatment selection was determined through a multidisciplinary clinical decision-making process involving the treating orthopedic surgeon and the anesthesiology team. Factors considered included anesthetic risk (ASA classification), overall medical condition, fracture characteristics, and the feasibility of achieving and maintaining acceptable closed reduction. Closed reduction was attempted in nearly all patients before the final treatment decision, unless immediate surgical intervention was deemed necessary based on fracture characteristics. Patients with acceptable reduction and higher perceived surgical risk were generally managed conservatively with casting, whereas patients in whom stable reduction could not be maintained or who were considered suitable for surgical fixation underwent volar locking plate fixation. In patients with both unacceptable reduction and prohibitive surgical risk, conservative management was continued with close radiographic and clinical follow-up.

Treatment Protocols

Cast Group

Closed reduction was performed without anesthesia, under manual traction and manipulation. A below-elbow plaster cast was applied in functional position. Neurovascular circulation was checked immediately after casting and patients were recalled the following day for repeat circulation control. Follow-up examinations were performed at week 3 and week 6, with clinical assessment and plain radiographs. In patients treated with casting, the plaster was removed at six weeks based on radiographic evidence of sufficient healing, and wrist mobilization exercises were initiated thereafter.

Volar Locking Plate Fixation Group

Patients in the surgical group underwent volar locking plate fixation through a standard modified Henry approach. Procedures were performed under general anesthesia or ultrasound-guided axillary nerve block, according to the patient’s overall medical condition and anesthesiology assessment.All surgical procedures were performed by experienced orthopedic surgeons specialized in trauma surgery, each with more than five years of clinical experience in the surgical management of distal radius fractures and following standardized institutional protocols.Following exposure of the distal radius, fracture reduction was achieved under fluoroscopic guidance. Fixation was performed using a precontoured volar locking plate system, applied in accordance with the manufacturer’s recommendations. Plate positioning, fracture alignment, and screw lengths were verified intraoperatively using fluoroscopy. Postoperatively, early finger and wrist range-of-motion exercises were encouraged as tolerated, in line with routine institutional rehabilitation protocols.

Outcome Measures

Functional Outcomes

- Patient-Rated Wrist Evaluation (PRWE): PRWE questionnaires were administered during outpatient visits at 6 and 12 months. Patients completed the validated PRWE form under supervision of an investigator, addressing both pain (0–10 Likert scale) and functional disability (0 = no difficulty, 10 = unable to do). Scores were calculated according to standard instructions, with a total score range of 0 (best) to 100 (worst).

- Visual Analog Scale (VAS): Pain intensity was assessed at rest (VAS-Rest) and during activity (VAS-Activity) using a 10-cm visual analog scale anchored by “no pain” (0) and “worst imaginable pain” (10). Measurements were recorded during outpatient visits at 6 and 12 months.

- Grip strength: Grip strength was measured with a Jamar® dynamometer at 6 and 12 months. Patients were seated with the shoulder adducted, elbow flexed to 90°, and forearm in neutral position. Three trials were performed with 30-second rest intervals, and the mean value was recorded. Results were expressed as an absolute value (kg) and as a percentage of the contralateral hand.

- Activities of Daily Living (ADL): Independence in activities of daily living was evaluated by structured interview at 3, 6, and 12 months. Patients were categorized as independent (1) or dependent (0) for essential tasks such as dressing, feeding, toileting, and personal hygiene.

Because of the nature of the interventions, blinding was not feasible during the collection of functional outcome measures.

Radiological Outcomes

Radiographs (PA and true lateral views) were obtained at baseline (post-reduction), 6 weeks, and 12 months. The following parameters were measured on the hospital PACS system using calibrated digital tools.

- Radial height (mm),

- Radial inclination (°),

- Volar tilt (°),

- Ulnar variance (mm).

Fracture union was defined as cortical bridging in at least three cortices and absence of pain at the fracture site.

Complications

Post-treatment complications were evaluated separately for each treatment group. In both the cast immobilization and volar locking plate fixation groups, the primary complications assessed included malunion and complex regional pain syndrome (CRPS). In the surgical group, implant-related complications were also recorded. All complications were identified based on clinical examination findings and review of medical records during scheduled follow-up visits.

Reliability Analysis

All radiographic measurements were performed independently by two fellowship-trained orthopedic surgeons using anonymized radiographs with patient identifiers removed. Because implants in the volar locking plate group were visible on radiographs, complete blinding to treatment allocation was not possible. To reduce observer-related bias, measurements were performed independently by two observers, and both intraobserver and interobserver reliability were assessed. To assess intraobserver reliability, each observer repeated all measurements after a 4-week interval. Interobserver reliability was evaluated by comparing measurements obtained by the two observers at the initial assessment. Reliability was quantified using intraclass correlation coefficients (ICC [2,1]), standard error of measurement (SEM), and minimum detectable change at the 95% confidence level (MDC95).

Power Analysis

An a priori power analysis was performed using G*Power version 3.1 (Heinrich-Heine-Universität Düsseldorf, Germany). Assuming a large effect size (Cohen’s d = 0.80), a significance level of α = 0.05, and a statistical power of 0.80, the minimum required sample size was calculated as 26 patients per group. This calculation was intended to estimate the minimum sample size required to detect a clinically meaningful between-group difference in functional outcomes. Based on the study period and eligibility criteria, 60 patients met the inclusion criteria and were included in the final analysis, with 30 patients in each treatment group.

Statistical Analysis

Statistical analyses were performed using IBM SPSS Statistics version 25.0 (IBM Corp., Armonk, NY, USA). The Shapiro–Wilk test was used to assess normality of data distribution. Normally distributed continuous variables were compared using the independent-samples t-test, with Levene’s test applied to evaluate homogeneity of variances. Non-normally distributed variables were analyzed using the Mann–Whitney U test. Categorical variables were compared using the chi-square test or Fisher’s exact test, as appropriate. Continuous data were presented as mean ± standard deviation or median with interquartile range (IQR), while categorical variables were expressed as frequencies and percentages. Effect sizes, including Cohen’s d, odds ratios, and risk ratios with 95% confidence intervals, were reported. A p-value <0.05 was considered statistically significant.

Results

During the study period, a total of 348 patients with distal radius fractures were identified from hospital electronic records (Figure 1). Of these, 66 pediatric patients, 160 adults younger than 65 years, 42 patients aged ≥65 years with ASA class I–II, 12 patients with highly comminuted intra-articular fractures (AO type C3) or fractures requiring emergency open reduction, and 8 patients with incomplete data or follow-up were excluded. Consequently, 60 patients were included in the final analysis, including 30 treated with cast immobilization and 30 treated with volar locking plate fixation.

Figure 1.

Flow diagram of patient selection and inclusion in the study

Table 1 summarizes the demographic characteristics of the study population. There were no statistically significant differences between the two groups in terms of age, sex distribution, fracture side, hand dominance, ASA classification, or comorbidity burden (all p>0.05). The mean age was 78.3 ± 8.6 years in the cast immobilization group and 78.0 ± 6.8 years in the volar locking plate group. Female patients represented the majority in both groups (66.7% vs. 73.3%). The distribution of ASA class III–IV patients and the proportion of patients with two or more comorbidities were also comparable between the groups.

Table 1.

Demographic Characteristics

Variable	Conservative (n=30)	Volar locking plate (n=30)	p value
Age (mean ± SD)	78.3 ± 8.6	78.0 ± 6.8	0.895
Female n (%)	20 (66.7%)	22 (73.3%)	0.778
Male n (%)	10 (33.3%)	8 (26.7%)	0.778
Right side n (%)	16 (53.3%)	14 (46.7%)	0.796
Left side n (%)	14 (46.7%)	16 (53.3%)	0.796
Dominant side fracture n (%)	13 (43.3%)	14 (46.7%)	1.000
Nondominant side n (%)	17 (56.7%)	16 (53.3%)	1.000
Asa class III n(%)	22(73.3%)	25(83.3%)	0.532
Asa class IV n(%)	8 (26.7%)	5 (16.7%)	0.532
Comorbidity count ≥2, n (%)	24 (80.0%)	23 (76.7%)	1.000

Statistical comparisons were performed as described in the Methods section.

Among the included patients, systemic comorbidities were frequently observed. The most common conditions were cardiovascular diseases (38.3%), diabetes mellitus (26.7%), chronic pulmonary disease (18.3%), chronic kidney disease (13.3%), and severe obesity (11.7%). Because several patients had more than one comorbid condition, these percentages were not mutually exclusive. The presence of multiple comorbidities contributed to the classification of many patients as ASA class III or IV. These comorbidities were identified based on preoperative anesthesiology evaluations and documented medical records.

Functional outcomes at 6 and 12 months are summarized in Table 2 and Figure 2. No statistically significant differences were observed between the cast immobilization and volar locking plate fixation groups in PRWE or VAS scores at either follow-up time point. Both groups demonstrated progressive improvement in wrist function and pain over time, indicating comparable recovery patterns across the two treatment modalities.

Table 2.

PRWE and VAS Scores at 6 and 12 Months

Variable	Conservative (n=30)	Volar locking plate(n=30)	p value*
PRWE – 6 months	26.7 ± 10.0	30.3 ± 16.3	0.302
PRWE – 12 months	19.3 ± 9.5	23.2 ± 9.5	0.114
VAS at rest – 6 months	1.8 ± 0.9	1.5 ± 0.9	0.239
VAS at rest – 12 months	1.2 ± 0.8	1.1 ± 1.0	0.824
VAS during activity – 6 months	3.0 ± 1.3	3.6 ± 1.2	0.086
VAS during activity – 12 months	2.5 ± 1.0	2.4 ± 1.1	0.879

*Statistical comparisons were performed using Student’s t-test for continuous variables. A p-value <0.05 was considered statistically significant.

Figure 2.

Comparison of PRWE scores at 6 and 12 months between the cast immobilization and volar locking plate fixation groups. Both groups demonstrated improvement over time, with no statistically significant between-group differences at either follow-up time point

Grip strength and independence in activities of daily living (ADL) are summarized in Tables 3 and 4, respectively, and grip strength trends are illustrated in Figure 3. There were no statistically significant differences between the cast immobilization and volar locking plate fixation groups in grip strength at either 6 or 12 months (p>0.05). Similarly, the proportion of patients who regained independence in ADL increased progressively over time in both groups, exceeding 90% at the 12-month follow-up, with no meaningful differences observed between the treatment groups.

Table 3.

Grip Strength at 6 and 12 Months (Mean ± SD)

Variable	Conservative (n=30)	Volar locking plate (n=30)	p value*
Grip strength – 6 months (%)	59.6 ± 10.7	59.9 ± 9.7	0.901
Grip strength – 12 months (%)	75.8 ± 9.7	76.9 ± 10.3	0.853

*Statistical comparisons were performed using Student’s t-test for continuous variables. A p-value <0.05 was considered statistically significant.

Table 4.

Independence in Activities of Daily Living (ADL)

Variable	Conservative (n=30)	Volar locking plate (n=30)	p value*
ADL independence – 3 months (%)	63.3%	66.7%	1.000
ADL independence – 6 months (%)	80.0%	73.3%	0.760
ADL independence – 12 months (%)	96.7%	93.3%	1.000

*Statistical comparisons were performed using Chi-square test for categorical variables. Fisher’s exact test was applied when expected counts were <5. A p-value <0.05 was considered statistically significant.

Figure 3.

Comparison of grip strength at 6 and 12 months between the cast immobilization and volar locking plate fixation groups. Grip strength improved in both groups over time, with no statistically significant between-group differences at either follow-up time point

Radiological parameters are summarized in Table 5. At baseline, no statistically significant differences were observed between the cast immobilization and volar locking plate fixation groups for any radiographic parameter (all p > 0.05). At the 12-month follow-up, radial height and radial inclination values were slightly higher in the volar locking plate group; however, these differences did not reach statistical significance (p > 0.05). In contrast, volar tilt and ulnar variance demonstrated significantly more favorable values in the volar locking plate fixation group at 12 months (p < 0.05). Overall, both treatment modalities achieved satisfactory radiographic restoration and maintained fracture reduction at final follow-up, with volar locking plate fixation providing superior maintenance of selected alignment parameters.

Table 5.

Radiological Parameters (Mean ± SD)

Parameter	Timepoint	Conservative (n=30)	Volar locking plate (n=30)	p value*
Radial height	Baseline (post-reduction)	8.4 ± 1.7	8.5 ± 1.6	0.842
Radial height	12 months	9.9 ± 1.6	10.3 ± 1.2	0.182
Radial inclination	Baseline (post-reduction)	18.3 ± 4.4	18.5 ± 4.1	0.871
Radial inclination	12 months	22.0 ± 3.4	22.6 ± 3.0	0.296
Volar tilt	Baseline (post-reduction)	-8.1 ± 7.1	-8.4 ± 7.0	0.906
Volar tilt	12 months	6.8 ± 5.6	9.2 ± 4.8	0.041
Ulnar variance	Baseline (post-reduction)	2.3 ± 1.3	2.2 ± 1.2	0.772
Ulnar variance	12 months	1.4 ± 1.1	0.8 ± 0.9	0.028

*Statistical comparisons were performed using Student’s t-test for continuous variables. A p-value <0.05 was considered statistically significant.

The intra- and inter-observer reliability of radiographic measurements demonstrated excellent agreement for all parameters (Table 6). ICC values ranged between 0.82 and 0.93, indicating good to excellent reliability across observers.

Table 6.

Intra- and Inter-observer Reliability of Radiographic Measurements

Parameter	Intra-observer ICC (95% CI)	Intra-observer SEM	Intra-observer MDC95	Inter-observer ICC (95% CI)	Inter-observer SEM	Inter-observer MDC95
Radial height (mm)	0.92 (0.86–0.96)	0.4	1.1	0.88 (0.80–0.94)	0.5	1.4
Radial inclination (°)	0.90 (0.83–0.95)	0.6	1.7	0.85 (0.76–0.92)	0.8	2.2
Volar tilt (°)	0.87 (0.78–0.93)	0.9	2.5	0.82 (0.71–0.90)	1.0	2.8
Ulnar variance (mm)	0.93 (0.87–0.97)	0.3	0.8	0.89 (0.81–0.94)	0.4	1.1

Post-treatment compli 301 cations are summarized in Table 7. Malunion was observed in 10 patients (33.3%) in the cast immobilization group and in 5 patients (16.7%) in the volar locking plate fixation group. Complex regional pain syndrome (CRPS) occurred in 8 patients (26.7%) in the cast immobilization group and in 3 patients (10.0%) in the volar locking plate fixation group. No major complications, including tendon rupture, neurovascular injury, deep infection, implant failure, or reoperation, were observed in either group during the follow-up period.

Table 7.

Post-treatment Complications and Risk Analysis

Complication	Cast (n, %)	Volar locking plate (n, %)	p value
Malunion	10 (33.3%)	5 (16.7%)	0.233
CRPS	8 (26.7%)	3 (10.0%)	0.181

Discussion

The present study specifically focuses on elderly patients with distal radius fractures and high anesthetic risk (ASA class ≥III) who were treated either with cast immobilization or volar locking plate fixation. This patient population represents a clinically important yet underrepresented subgroup, as frail elderly individuals with significant comorbidities are frequently excluded from prospective trials. To our knowledge, comparative data evaluating operative versus nonoperative treatment strategies exclusively in this high-risk cohort remain limited.^3,8,9 While numerous studies have compared volar plating with conservative treatment in heterogeneous or medically fit populations, evidence addressing treatment outcomes in elderly patients with compromised physiological reserve is scarce. In the present study, functional and radiological outcomes at one-year follow-up were comparable between volar locking plate fixation and cast immobilization. Given the absence of clear long-term functional superiority and the inherently nonoperative nature of casting, conservative treatment may remain a reasonable first-line option in carefully selected elderly patients when acceptable fracture reduction can be achieved.

Several recent studies have compared surgical and conservative treatment modalities for distal radius fractures in the elderly and have reported largely comparable functional outcomes. Hassellund et al demonstrated that cast immobilization was non-inferior to volar locking plate fixation in terms of QuickDASH scores at one-year follow-up in patients aged 65 years and older.⁷ Likewise, the meta-analysis by Ochen et al, which included over 3000 patients, found no consistent superiority of surgical intervention over nonoperative care in terms of PRWE, DASH, or VAS improvements beyond six months.⁵ Similarly, Saving et al reported minimal differences in long-term wrist function between surgical and conservative treatment strategies in elderly patients, including those with a higher burden of comorbidities.¹⁰ In line with these findings, our study revealed no significant differences between cast immobilization and volar locking plate fixation with respect to PRWE, VAS, grip strength, or activities of daily living at both 6- and 12-month follow-up. Importantly, our cohort was restricted to patients with ASA class ≥III or severe medical comorbidities, representing a frail population frequently excluded from prior clinical trials. The comparable functional recovery observed in this high-risk group suggests that achieving and maintaining stable fracture reduction, rather than employing a more invasive fixation method, may be sufficient to ensure satisfactory wrist function in elderly patients with limited physiological reserve.

The relationship between radiological parameters and clinical outcomes in elderly patients with distal radius fractures remains a subject of ongoing debate. Although surgical fixation techniques often achieve superior radiographic restoration, the functional relevance of attaining near-anatomical alignment in this age group appears limited. Evidence from large randomized trials suggests that improved alignment does not necessarily translate into superior long-term functional outcomes. In the DRAFFT trial, Costa and colleagues demonstrated that despite better radiographic alignment following surgical fixation, long-term patient-reported functional outcomes did not differ significantly from those achieved with closed reduction and cast immobilization.¹¹ Similarly, Aggarwal et al reported that radiological parameters beyond certain thresholds—such as volar tilt or ulnar variance—were not independent predictors of improved PRWE scores or grip strength in patients aged over 65 years.¹² Earlier work by Kreder et al also showed that acceptable alignment and fracture union can be achieved with nonoperative methods when early reduction stability is maintained, particularly in osteoporotic bone.¹³ In the present study, volar tilt and ulnar variance at 12 months were more favorable in the volar locking plate fixation group, whereas radial height and radial inclination were comparable between treatment groups. Importantly, these radiographic differences were modest in magnitude and did not translate into significant differences in functional outcomes, fracture union, or activities of daily living. These findings are consistent with systematic reviews and meta-analyses indicating that radiographic refinement beyond functional thresholds offers limited additional clinical benefit in elderly or medically comorbid individuals.⁵ Collectively, our results suggest that long-term functional recovery in this population depends more on maintaining stable reduction and adherence to rehabilitation protocols than on achieving maximal radiographic correction. Complications following distal radius fractures in elderly patients have been widely reported, although their incidence and clinical relevance vary according to patient characteristics and treatment modality. Gutiérrez-Monclus et al identified malunion as the most common radiographic complication after conservative treatment; however, its impact on long-term functional outcomes was limited in patients over 60 years of age.¹⁴ Similarly, Young and Rayan demonstrated that moderate residual deformity after nonoperative management did not substantially impair wrist motion or grip strength in low-demand elderly individuals.¹⁵ Complex regional pain syndrome (CRPS) has been described after both operative and nonoperative treatment of distal radius fractures, with reported incidence rates ranging between approximately 2% and 7%. Jellad et al identified fracture severity and prolonged immobilization as relevant risk factors, whereas a recent meta-analysis by Lorente et al confirmed that CRPS development is multifactorial and not exclusively related to the choice of surgical technique.^16,17. In elderly patients, additional factors such as prolonged immobilization, advanced age, fracture severity, and underlying comorbidity burden may further contribute to CRPS development. The relatively high CRPS rates observed in both groups in the present study may therefore reflect the frailty and multimorbidity of the study population rather than a treatment-specific effect.¹⁸ Regarding surgical treatment, previous studies focusing on volar locking plate fixation have reported that most complications are minor and that major events such as tendon rupture, deep infection, or reoperation remain relatively uncommon in elderly populations. Arora et al reported comparable overall complication rates between volar plating and conservative treatment, despite differences in radiographic alignment.³ Similarly, Aparicio et al and Søsborg-Würtz et al emphasized that complication risk in older patients is more closely associated with bone quality, comorbidities, and soft-tissue condition than with the specific fixation method employed.^19,20 In the present study, malunion and CRPS were observed in both the cast immobilization and volar locking plate fixation groups, with higher—but not statistically significant—rates in the conservatively treated cohort. Importantly, no major complications such as deep infection, tendon rupture, neurovascular injury, implant failure, or reoperation were encountered in either group. Collectively, these findings support previous evidence suggesting that in frail elderly patients, stable reduction and appropriate follow-up care are more critical determinants of outcome than the invasiveness of the fixation technique itself. However, these differences should be interpreted with caution given the relatively small sample size and the wide confidence intervals observed in the risk estimates.

This study has several limitations that should be acknowledged. First, its single-center design may limit the generalizability of the findings to other populations or healthcare systems. Second, the retrospective nature of the study restricted the ability to control for all potential confounding variables, including fracture pattern severity and residual confounding by indication. Because treatment allocation was based on clinical judgment rather than randomization, selection bias cannot be completely excluded. Additionally, heterogeneity in comorbidity burden and adherence to postoperative rehabilitation protocols among elderly patients may have influenced functional outcomes. Functional demand levels were not formally quantified in this cohort; however, most patients represented a low-demand geriatric population with multiple comorbidities and limited physical activity. This factor should be considered when interpreting the functional outcomes observed in the present study. Despite these limitations, the present study reflects real-world clinical practice and provides clinically relevant insight into the management of distal radius fractures in frail, high-risk geriatric patients for whom the balance between surgical benefit and procedural risk is particularly critical.

Conclusion

In elderly patients with distal radius fractures and significant medical comorbidities that increase perioperative risk, both cast immobilization and volar locking plate fixation resulted in comparable functional outcomes at one-year follow-up. Although volar locking plate fixation provided more favorable radiological alignment in selected parameters, this advantage did not translate into superior patient-reported outcomes, grip strength, or independence in activities of daily living.

Footnotes

Acknowledgments

The authors would like to thank the staff of the Orthopaedics and Traumatology Department at Sincan Training and Research Hospital for their valuable support during data collection and patient follow-up.

ORCID iDs

Nihat Yiğit

Nuri Koray Ülgen

Ethical Considerations

This study was approved by the Institutional Ethics Committee (Approval No: E1-21-2266). The study was conducted in accordance with the Declaration of Helsinki.

Consent to Participate

The requirement for informed consent was waived due to the retrospective nature of the study.

Consent for Publication

This study contains no individual personal data, images, or videos requiring consent for publication.

Author Contributions

NY (Nihat Yiğit): Conceptualization, data analysis, and manuscript drafting. ASN (Ali Said Nazlıgül): Data collection. NKÜ (Nuri Koray Ülgen): Statistical analysis and critical review. MOA (Mehmet Orçun Akkurt): Methodology oversight and supervision. SEE(Sadık Emre Erginoğlu): Literature review.MB (Murat Bozbek): Clinical validation and final review. All authors have read and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.*

References

Jayaram

Yoon

Kane

Wang

Chung

. Comparison of Distal Radius Fracture Outcomes in Older Adults Stratified by Chronologic vs Physiologic Age Managed With Casting vs Surgery. JAMA Netw Open. 2023;6(2):e2255786. doi:10.1001/jamanetworkopen.2022.55786.

Nellans

Kowalski

Chung

. The epidemiology of distal radius fractures. Hand Clin. 2012;28(2):113-125. doi:10.1016/j.hcl.2012.02.001.

Arora

Lutz

Deml

Krappinger

Haug

Gabl

. A Prospective Randomized Trial Comparing Nonoperative Treatment with Volar Locking Plate Fixation for Displaced and Unstable Distal Radial Fractures in Patients Sixty-five Years of Age and Older. JBJS. 2011;93(23):2146-2153. doi:10.2106/JBJS.J.01597.

Luttwak

Ibelli

Taub

Melamed

Wiser

. Predicting early term complications of ORIF distal radius fracture in outpatient settings using NSQIP data. Injury. 2023;54(6):1650-1656. doi:10.1016/j.injury.2023.04.008.

Ochen

Peek

Van Der Velde

, et al. Operative vs Nonoperative Treatment of Distal Radius Fractures in Adults: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(4):e203497. doi:10.1001/jamanetworkopen.2020.3497.

Gullborg

Kim

Ward

Simcock

. Optimizing Treatment Strategies for Distal Radius Fractures in Osteoporosis: A Comparative Review. Medicina (Mex). 2024;60(11):1848. doi:10.3390/medicina60111848.

Hassellund

Williksen

Laane

, et al. Cast immobilization is non-inferior to volar locking plates in relation to QuickDASH after one year in patients aged 65 years and older: a randomized controlled trial of displaced distal radius fractures. Bone Jt J. 2021;103-B(2):247-255. doi:10.1302/0301-620X.103B2.BJJ-2020-0192.R2.

Shukla

Jain

Sharma

Kumar

. External fixation versus volar locking plate for displaced intra-articular distal radius fractures: a prospective randomized comparative study of the functional outcomes. J Orthop Traumatol Off J Ital Soc Orthop Traumatol. 2014;15(4):265-270. doi:10.1007/s10195-014-0317-8.

LCP Study Group Jupiter

Marent-Huber

. Operative management of distal radial fractures with 2.4-millimeter locking plates: a multicenter prospective case series. Surgical technique. J Bone Joint Surg Am. 2010;92(Suppl 1 Pt 1):96-106. doi:10.2106/JBJS.I.01340.

10.

Saving

Severin

Olsson

, et al. Nonoperative Treatment Compared with Volar Locking Plate Fixation for Dorsally Displaced Distal Radial Fractures in the Elderly: A Randomized Controlled Trial. J Bone Joint Surg Am. 2019;101(11):961-969. doi:10.2106/JBJS.18.00768.

11.

Costa

Achten

Plant

, et al. UK DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius. Health Technol Assess. 2015;19(17):1-124. doi:10.3310/hta19170.

12.

Aggarwal

Sinha

Kumar

Qureshi

Jameel

. Predictors of Functional Outcomes of Nonoperatively Treated Extra-articular Distal End Radius Fractures in Older Individuals: A Prospective Clinical Study. Hand N Y N. 2026;21:15589447241305421. doi:10.1177/15589447241305421. Published online December 20, 2024.

13.

Kreder

Agel

McKee

Schemitsch

Stephen

Hanel

. A randomized, controlled trial of distal radius fractures with metaphyseal displacement but without joint incongruity: closed reduction and casting versus closed reduction, spanning external fixation, and optional percutaneous K-wires. J Orthop Trauma. 2006;20(2):115-121. doi:10.1097/01.bot.0000199121.84100.fb.

14.

Gutiérrez-Monclus

Gutiérrez-Espinoza

Zavala-González

Olguín-Huerta

Rubio-Oyarzún

Araya-Quintanilla

. Correlation Between Radiological Parameters and Functional Outcomes in Patients Older Than 60 Years of Age With Distal Radius Fracture. Hand N Y N. 2019;14(6):770-775. doi:10.1177/1558944718770203.

15.

Young

Rayan

. Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years. J Hand Surg. 2000;25(1):19-28. doi:10.1053/jhsu.2000.jhsu025a0019.

16.

Jellad

Salah

Ben Salah Frih

. Complex Regional Pain Syndrome Type I: Incidence and Risk Factors in Patients With Fracture of the Distal Radius. Arch Phys Med Rehabil. 2014;95(3):487-492. doi:10.1016/j.apmr.2013.09.012.

17.

Lorente

Mariscal

Lorente

. Incidence and risk factors for complex regional pain syndrome in radius fractures: meta-analysis. Arch Orthop Trauma Surg. 2023;143(9):5687-5699. doi:10.1007/s00402-023-04909-8.

18.

Liu

Zhang

. Dynamic risk factors for complex regional pain syndrome after distal radius fracture surgery: multivariate analysis and prediction. BMC Musculoskelet Disord. 2024;25:899. doi:10.1186/s12891-024-07948-3.

19.

Aparicio

Izquierdo

Castellanos

. Conservative Treatment of Distal Radius Fractures: A Prospective Descriptive Study. HAND. 2018;13(4):448-454. doi:10.1177/1558944717708025.

20.

Søsborg-Würtz

Gellert

Erichsen

Viberg

. Closed reduction of distal radius fractures: a systematic review and meta-analysis. EFORT Open Rev. 2018;3(4):114-120. doi:10.1302/2058-5241.3.170063.