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Our retrospective study published in the Journal of Hand Surgery establishes a connection between low bone density and painful wrist fracture healing, suggesting surgery could be a preferred treatment for some patients.
Fractures of the wrist are common, especially among older patients. Our research demonstrates that patients with low bone density are more likely to have more significant shifting in the bones when they’re allowed to heal with non-surgical treatment, resulting in more positive ulnar variance that can be quite painful and limit movement. With this information, providers can have more nuanced conversations about treatment options with patients who may benefit from surgery.
The forearm contains two bones, the thumb-side radius and the pinky-side ulna. A distal radius fracture (DRF) is a break in the radius near the wrist joint. It is often caused by a fall onto an outstretched arm. The radius is the most frequently broken bone in the arm, and the injury happens most often among older adults. DRF accounts for 18% of all fractures in people over age 65.
It is possible to treat many DRFs without surgery. However, this can shorten the radius slightly during healing in some patients while the ulna stays at its average length. This asymmetry, in which the ulna is longer than the radius, is called positive ulnar variance. It can limit function and range of motion in the wrist and cause long-term pain.
For less-displaced (in acceptable position) fractures, clinical practice guidelines say surgery usually isn’t necessary because non-surgical treatment outcomes, such as a wrist splint or a cast, can be just as effective with fewer risks and less expense. But for some patients, an uncomplicated fracture can become displaced in the first few weeks of healing. One of the ways the bone can displace (move) leads to positive ulnar variance, among other problems.
In our ongoing work to provide the best fracture care for patients, our research sought to understand the relationship between low bone density and this development of positive ulnar variance and whether we could learn which fractures are more likely to shift to help patients decide whether surgery might be their best option.
Study methods and results.
Our researchers reviewed the medical records of 304 DRF patients treated without surgery. We analyzed these patients’ bone density measurements to check for osteoporosis (low bone density) and assessed the stability of their fractures. We also noted several precise measurements of their wrist joints before and after treatment, including the angle and height of the radius, ulnar variance, and more.
The statistical analysis results were precise: after six weeks of non-surgical treatment, there was an average additional increase of 1.4 millimeters in ulnar variance across patients with lower bone density, showing that patients with lower bone density and unstable fractures had a more significant increase in ulnar variance.
This knowledge allows us to have more informed discussions with patients about how best to treat DRF. It underlines the importance of measuring a patient’s bone density in treatment decisions.
For example, if I care for two 70-year-old patients with similar fractures, I can anticipate that if one patient has low bone density, they are more likely to have shifting of the fracture than the patient who does not. Based on this research, my conversation with the patient will inform them that, based on their imaging and bone density, we are more concerned that their fracture will shift. This patient may decide to pursue surgery to prevent this risk. If they choose non-surgical treatment, we will follow them closely to try and catch early signs of fracture shifting and intervene at that point.
Better decision-making means better treatment.
Our next steps will be to track these questions in real-time rather than in a retrospective study.
In collaboration with the Bone Health and Fracture Prevention Program at MedStar Health, we hope to learn whether patients who receive treatment for low bone density can have better fracture outcomes, fewer repeat fractures, or fewer fractures altogether. If we can help patients address bone density problems, we can potentially prevent future fractures and improve quality of life.
I’m proud to be conducting this research at MedStar Health Research Institute, where we support leading care by asking questions others haven’t thought to ask and get answers that make a real difference in patient care.