Abstract
Introduction
Distal radius fractures are common in older women, but the optimal treatment remains debated. We compared conservative treatment, volar locking plate fixation, and external fixation in women aged ≥65 years with low-energy distal radius fractures, focusing on patient-reported outcomes (PROMs) and radiographic alignment.
Materials and Methods
This retrospective cohort study included consecutive women aged ≥65 years treated at a tertiary center between January 2019 and January 2024. Only low-energy mechanisms, such as falls from standing height, were included. Patients were grouped according to treatment received: conservative management (n=44), open reduction and internal fixation with a volar locking plate (ORIF; n=47), or external fixation (n=43). The primary endpoint was the PRWE total score at ≥12 months. Secondary outcomes included QuickDASH, PRWE pain and function subscores, range of motion, grip strength, and radiographic parameters.
Results
A total of 134 women were analyzed. The primary outcome, PRWE total score, did not differ significantly across groups: 15.40±6.71 after conservative treatment, 14.89±5.55 after volar plating, and 17.08±7.51 after external fixation (p=0.268). QuickDASH scores were 14.35±7.21, 17.86±6.57, and 15.44±7.61, respectively (p=0.058). Grip strength as a percentage of the contralateral side was also similar (88.62±5.85%, 90.09±5.54%, and 91.02±5.54%; p=0.139). Patients selected for operative treatment had better final radiographic alignment, including volar tilt (5.80±2.79°, 7.55±1.57°, and 7.07±1.65°; p<0.001) and radial height (9.73±2.42 mm, 11.77±1.91 mm, and 12.86±1.91 mm; p<0.001).
Conclusions
In women aged ≥65 years with low-energy distal radius fractures, PRWE total score did not differ significantly across treatment pathways, despite better radiographic alignment in patients selected for operative treatment. Because treatment allocation was not randomized and baseline fracture morphology differed substantially between groups, these comparisons should be interpreted as descriptive observational findings after individualized treatment selection in routine practice. The absence of statistically significant differences in PROMs should not be interpreted as evidence of treatment equivalence or as a causal treatment effect.
Keywords
Introduction
Distal radius fractures are among the most common fragility fractures in older adults, particularly in women, and they frequently occur after low-energy falls.1-3 In older women, these fractures may compromise independence and daily hand use during recovery. Epidemiologic studies have identified age, sex, and bone health as key risk factors, placing these fractures within the spectrum of fragility injuries.1,2
Although many older patients can be treated successfully without surgery, management remains variable when displacement, intra-articular extension, or instability is present. In this population, the central clinical question is not simply whether operative treatment can restore radiographic alignment, but whether this improvement results in better patient-centered recovery. Randomized trials comparing volar locking plate fixation with closed reduction and cast immobilization in older patients have reported mixed findings. Some studies have suggested earlier recovery or modest functional benefit after surgery in selected displaced fractures, whereas others have found no clinically important long-term superiority of plating over casting in wrist pain, function, or QuickDASH outcomes.4-7
More recent trials suggest that volar plating may offer modest short-term benefit in selected displaced fractures, but whether this advantage is clinically important remains unclear.8,9
Another unresolved issue is the clinical relevance of final radiographic alignment in older patients. Prior studies suggest that radiographic parameters correlate weakly with PROMs in older patients.10,11
Because distal radius fractures are common in older women, focused data from this population are therefore needed. The present study compared conservative treatment, volar locking plate fixation, and external fixation in women aged ≥65 years with low-energy distal radius fractures. We aimed to evaluate whether surgical treatment was associated with better radiographic alignment and whether this translated into superior objective function or PROMs at a minimum follow-up of 12 months.
Materials and Methods
This retrospective cohort study included consecutive women aged ≥65 years who were treated for an acute low-energy distal radius fracture at a tertiary referral center between January 2019 and January 2024. The study was conducted in accordance with the Declaration of Helsinki and was approved by the local ethics committee. Patients were identified through the institutional electronic medical record system.
Eligible patients had a radiographically confirmed distal radius fracture, received conservative treatment, volar locking plate fixation, or external fixation, and had complete clinical, radiographic, and PROM data at a minimum follow-up of 12 months. Low-energy trauma was defined as a fall from standing height or a comparable simple slip/trip mechanism. Patients with high-energy trauma, open fractures, associated ipsilateral upper-extremity injuries, pathological fractures, prior ipsilateral wrist surgery, unavailable minimum 12-month follow-up, inability to contact, missing final clinical or PROM data, or incomplete medical records were excluded. The final analysis was restricted to patients with complete follow-up and outcome data.
Fractures were classified according to the AO/OTA system using initial wrist radiographs. Two orthopedic surgeons reviewed the images independently. When there was disagreement, the films were re-examined together and a final classification was reached by consensus. Treatment choice was determined by the treating surgeon according to routine institutional practice, considering fracture morphology, displacement, articular involvement, comminution, post-reduction alignment, instability, and patient-related surgical suitability. In patients who underwent closed reduction, continued conservative treatment was selected when post-reduction alignment was considered acceptable and stable. Operative treatment was generally considered when acceptable alignment could not be achieved or maintained, particularly in fractures with relevant residual displacement, intra-articular incongruity, radial shortening, instability, comminution, or loss of reduction during early follow-up. These principles were not applied as rigid thresholds, and final decision-making also incorporated patient-related factors, functional demand, surgical suitability, and patient preference.
Conservative treatment consisted of closed reduction when indicated, followed by cast immobilization and routine outpatient follow-up. The volar plate group underwent open reduction and internal fixation with a volar locking plate using standard technique. In the external fixation group, spanning external fixation was applied, with supplementary percutaneous Kirschner-wire fixation when additional stability was required. Patients were analyzed according to the definitive treatment received.
Post-treatment rehabilitation followed institutional practice. Wrist mobilization was started after cast removal in the conservative group, after wound review in the volar plate group, and after fixator removal in the external fixation group. External fixators, and supplementary K-wires when used, were removed as planned at approximately 6 weeks.
Recorded baseline variables included age, injured side, hand dominance, dominant-side involvement, AO/OTA fracture type, and follow-up duration. Pre-fracture functional status, frailty, and comorbidity data were unavailable in the retrospective records. Radiographic outcomes were measured on follow-up wrist radiographs and included volar tilt (degrees), radial height (mm), radial inclination (degrees), and ulnar variance (mm). Functional evaluation included wrist range of motion (flexion, extension, pronation, supination, radial deviation, and ulnar deviation) and grip strength measured on both sides and expressed as a percentage of the contralateral limb.
Outcomes were assessed at each patient’s most recent outpatient follow-up visit, provided the minimum follow-up was at least 12 months. PROMs were obtained at final follow-up using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Patient-Rated Wrist Evaluation (PRWE) questionnaires, which were completed during the outpatient visit or, when an in-person visit was not possible, by telephone interview. The PRWE was reported as pain, function, and total scores; for both QuickDASH and PRWE, higher scores indicate greater disability or worse symptoms. The primary outcome was the PRWE total score at final follow-up. Secondary outcomes included QuickDASH score, PRWE pain and function subscores, wrist range of motion, grip strength, and radiographic parameters including volar tilt, radial height, radial inclination, and ulnar variance.
Statistical analyses were performed with IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY, USA). No formal a priori sample size calculation was performed because of the retrospective design. The study included all consecutive patients who met the eligibility criteria and had complete final follow-up and outcome data during the study period. Normality was assessed using visual inspection and the Shapiro–Wilk test. Continuous variables that met the normality assumption were summarized as mean ± SD and compared using one-way ANOVA; those that did not were also reported as mean ± SD for consistency but compared using the Kruskal–Wallis test. Categorical variables were reported as counts and percentages and compared using the chi-square test or Fisher’s exact test, as appropriate. When an overall between-group difference was detected for continuous variables, post-hoc pairwise comparisons were performed using Bonferroni correction after one-way ANOVA and Dunn–Bonferroni correction after the Kruskal–Wallis test. A two-sided p value < 0.05 was considered statistically significant. Given the retrospective design and non-randomized treatment allocation, all between-group comparisons were considered descriptive and observational, and no causal inference or equivalence testing was intended.
Results
A total of 134 women aged ≥65 years with distal radius fractures were included in the study and treated with one of three selected treatment strategies: conservative treatment (n = 44), open reduction and internal fixation with a volar locking plate (ORIF, n = 47), and external fixation (n = 43). The participant selection process is shown in Figure 1, and baseline demographic and injury-related characteristics are summarized in Table 1. Patient selection flow diagram Baseline Characteristics and Follow-up Duration by Treatment Group Values are presented as mean ± SD (95% CI) or n (%). Continuous variables were compared using one-way ANOVA or the Kruskal–Wallis test, as appropriate. Categorical variables were compared using the Pearson chi-square (χ2) test or Fisher’s exact test, as appropriate. ORIF, open reduction and internal fixation.
The proportion of right-versus left-sided fractures, hand dominance, and dominant-side involvement did not differ significantly. In contrast, fracture morphology varied by treatment strategy: extra-articular (AO type A) fractures were most frequently treated conservatively, whereas the ORIF and external fixation groups included a higher proportion of articular fractures (AO types B and C) (Table 1). This imbalance indicates that the treatment groups were different at baseline in terms of fracture morphology.
Final Clinical, Radiographic, and PROMs by Treatment Group
Values are presented as mean ± SD (95% CI). P values were obtained using one-way ANOVA or the Kruskal–Wallis test, as appropriate. Significant Bonferroni pairwise differences were denoted as aConservative–ORIF, bConservative–External fixator, cORIF–External fixator. ORIF, open reduction and internal fixation; QuickDASH, Quick Disabilities of the Arm, Shoulder and Hand; PRWE, Patient-Rated Wrist Evaluation.
Radiographic parameters demonstrated clearer separation between treatment approaches. Patients selected for operative treatment showed better final radiographic alignment than those managed conservatively, particularly for volar tilt and radial height; radial inclination also differed across groups, while ulnar variance was similar.
Discussion
In this retrospective cohort, patients selected for operative treatment had better final radiographic alignment, particularly in volar tilt and radial height, whereas PROMs were similar across the selected treatment pathways at ≥12 months. More complex or unstable fractures were generally treated operatively, while fractures considered acceptable and stable after reduction were more often managed conservatively. Therefore, the convergence of PROMs may reflect appropriate treatment selection in routine practice rather than direct evidence of treatment equivalence or superiority. Because treatment allocation was not randomized and fracture morphology differed substantially between groups, the results cannot be extrapolated to define indications for non-operative management in complex AO/OTA type B or C fractures.
Our results are consistent with the best available long-term comparative evidence. The WRIST randomized trial in older adults found no meaningful differences in PROMs at 24 months across casting, volar locking plates, external fixation (±pinning), and percutaneous pinning, despite differences in alignment and malunion rates. 12 Similarly, a randomized non-inferiority trial in patients aged ≥65 years reported that casting was non-inferior to volar locking plate fixation with respect to QuickDASH at one year. 4 Together, these data support the idea that many older patients can achieve satisfactory long-term function even when radiographs are less than ideal, provided pain settles and hand use is regained.
More recent randomized evidence has provided a more nuanced view of the role of volar locking plate fixation in older patients with distal radius fractures. Saving et al. reported that volar locking plate fixation provided better clinical outcomes than nonoperative treatment in elderly patients with dorsally displaced distal radius fractures, although the magnitude and clinical relevance of this benefit should be interpreted cautiously in relation to patient age and functional demand. 6 In contrast, the CROSSFIRE randomized clinical trial by Lawson et al. found no clinically important difference in wrist pain or function at 12 months between volar locking plate fixation and closed reduction, although patient-reported treatment success favored surgery. 7 Its 24-month secondary analysis similarly showed no clinically important functional superiority of plating, despite higher treatment success in the surgical group. 13 Longer-term randomized follow-up by Südow et al. suggested that volar locking plate fixation may reduce disability in severely displaced fractures in patients over 70 years, but this benefit should be weighed against its modest magnitude and the baseline fracture pattern. 9 Most recently, the DRIFT trial showed that volar locking plating provided a statistically significant 12-month PRWE benefit in primarily malaligned fractures, but the effect was smaller than the predefined minimal clinically important difference; in fractures that lost alignment during early follow-up, surgery did not provide a clinically important benefit. 14 Taken together, these trials suggest that surgery may offer faster recovery or modest benefit in selected older patients, particularly those with displaced or primarily malaligned fractures, but radiographic improvement alone does not consistently translate into clinically meaningful long-term functional superiority.
In our cohort, patients selected for operative fixation showed better radiographic results, while PROMs were similar across treatment options at follow-up in women aged ≥65 years with low-energy distal radius fractures. One possible interpretation is that operative treatment was selected for fractures with greater complexity or instability, whereas conservative care was selected for fractures considered acceptable and stable. The similar PROMs may therefore reflect appropriate individualized treatment selection rather than a simple absence of benefit from surgery. This is consistent with studies showing similar functional outcomes despite better alignment after plating.5,15-17 Likewise, systematic reviews suggest that although operative treatment improves alignment and may provide earlier clinical benefit, differences in PROMs can diminish over time, particularly in older populations. 18 The numerically higher QuickDASH score in the ORIF group, despite better radiographic alignment, should also be interpreted cautiously. Although this difference was not statistically significant, it may reflect greater baseline fracture complexity in patients selected for plating, residual stiffness, soft-tissue effects related to surgery, or residual confounding by indication rather than a direct adverse effect of ORIF itself.
Although volar tilt, radial height, and radial inclination differed statistically between groups, the absolute magnitude of these differences should be considered when interpreting their clinical relevance. Compared with the conservative group, the mean differences in volar tilt were approximately 1.3° to 1.8°, and the differences in radial inclination were approximately 2.1° to 2.6°. These angular differences are relatively small and may be below the threshold expected to produce a measurable functional or PROM benefit in many older patients. Radial height differed by approximately 2.0 to 3.1 mm between conservative and operative treatment groups, which may be more radiographically apparent, but its clinical relevance remains uncertain in the absence of corresponding differences in PROMs, grip strength, or range of motion. In addition, ulnar variance did not differ significantly between groups, which may partly explain the similar PROM findings. Therefore, statistical significance in radiographic parameters should not be interpreted automatically as clinical significance in this population. A recent review and meta-analysis found that although poor alignment is statistically linked to worse PROMs, the size of these differences often does not meet the commonly accepted thresholds for minimal clinically important change. 10 This helps explain why the radiographic gains observed after surgery in our cohort may not have translated into a measurable PROM advantage at later follow-up.
Because surgeons preferentially operated on more complex fractures, selection bias may have masked true between-group differences in PROMs. Ideally, conducting sensitivity analyses based on fracture severity (such as AO type) or using adjusted models would help explore whether the convergence of PROM results was influenced by baseline fracture complexity. However, our sample size was too small to perform such sensitivity analyses reliably. The weak correlation between final alignment and 12-month PROMs reported by Lawson et al. 11 supports this dissociation. Radiographic gains may therefore not be mirrored by PROMs differences. 11
The value of our study is that it provides real-world, sex-specific evidence in a group that dominates fragility wrist fracture epidemiology but is often diluted in mixed cohorts. By focusing on postmenopausal women with low-energy falls and providing a three-way comparison (conservative vs volar plate vs external fixation) using both wrist-specific and region-based PROMs, our results directly inform day-to-day geriatric decision-making. In practice, they reinforce a patient-centered message: for many older women, improving radiographs alone may not guarantee better recovery at ≥12 months.
The most important limitation of this study is confounding by indication. Treatment allocation was not randomized, and the groups were fundamentally different in terms of baseline fracture morphology. Therefore, causal inference is substantially limited, and the observed similarity in PROMs cannot be interpreted as proof that the treatment strategies produce equivalent outcomes. As a result, fracture characteristics were not balanced between groups. The conservative group mainly included extra-articular AO type A fractures, whereas the operative groups included a higher proportion of AO type B and C fractures. This imbalance limits the validity of direct comparisons between treatment strategies, substantially restricts causal inference, and prevents the similar long-term PROMs from being interpreted as evidence of equivalence between operative and non-operative treatment. Although stratified analyses by AO/OTA fracture type or adjusted methods such as multivariable regression or propensity score analysis could theoretically reduce this bias, the limited sample size and sparse, uneven subgroup distribution across treatment arms would make such analyses statistically unstable and potentially misleading.
Several other potentially important confounders were also not consistently available in the retrospective records, including bone mineral density, osteoporosis diagnosis or treatment, comorbidity burden, frailty, pre-injury functional status, baseline PROMs, detailed initial displacement, time from injury to treatment, and rehabilitation intensity. These factors may have influenced both treatment selection and recovery, but could not be incorporated into the analyses. In a geriatric population, this limitation is particularly relevant because pre-fracture functional status, frailty, osteoporosis status or treatment, and comorbidity burden may influence treatment selection, rehabilitation potential, functional recovery, and PROMs. Therefore, the unavailability of these baseline clinical variables may have contributed to residual confounding and should be considered when interpreting the findings. Follow-up-related selection bias should also be considered, as patients with uncomplicated recovery, particularly those with simpler fractures treated conservatively, may have been less likely to continue long-term follow-up. In addition, detailed baseline data were not systematically extracted for patients excluded because of inadequate follow-up, inability to contact, prior surgery, missing final outcome data, or incomplete records; therefore, we could not compare excluded and included patients with respect to age, fracture classification, or initial treatment pathway. Consequently, the direction and magnitude of potential attrition bias cannot be determined. Finally, outcomes were assessed only at final follow-up, so potential early functional advantages of surgery could not be evaluated. These limitations should be considered when interpreting the finding that patients selected for operative treatment had better radiographic alignment, while PROMs at ≥12 months were similar across groups.
Conclusion
In women aged ≥65 years with low-energy distal radius fractures, patients selected for operative treatment demonstrated better final radiographic alignment despite having more complex fracture patterns, whereas PROMs at ≥12 months were similar across selected treatment pathways. These findings should be interpreted as descriptive observational outcomes after individualized treatment selection in routine practice, not as evidence of equivalence between operative and non-operative treatment. Because of the retrospective design, unequal fracture-pattern distribution, and absence of baseline frailty or pre-fracture functional data, causal inference is substantially limited, and the results should not be used to define treatment indications. Radiographic improvement alone may therefore have limited ability to predict patient-reported recovery in this population.
Footnotes
Ethical Considerations
Ethical approval was obtained from the İzmir Bakırçay University Non-Interventional Clinical Research Ethics Committee (Decision No: 2683; 07 January 2026).
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of Conflicting Interests
The authors declare 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.
AI Use
The authors acknowledge the use of artificial intelligence–assisted tools to support the preparation of this manuscript, editing and refining the academic English language for clarity, coherence, and consistency. All scientific content, interpretations, and conclusions remain the sole responsibility of the authors, and the manuscript was reviewed and finalized by the authors to ensure accuracy and integrity.
Note on Anonymity
To maintain anonymity during peer review, any identifying information related to authors, institutions, funders, or approval committees should appear on this title page only and be removed from the blinded manuscript file.