One of my mentors, well into his 70s at the time of my fellowship, when presented with a dorsal ganglion, still presented the traditional option of hitting it with a book. I saw him do it just once, but he flashed a grin, said, “I have a special book for this,” went back to his office and returned with an encyclopedia-sized tome entitled, “Fifty Years of Orthopaedic Progress.”
Recent years have seen a sea change in treatment of distal radius fractures, evolving from limited fixation and largely closed treatment, to a generation of external fixation and Kapandji pinning, to locked plating and fragment-specific fixation. With the ease of application of modern volar plates, the decision to offer surgery to a patient with a displaced fracture has become easier. The question always remains whether technology has outrun indications, or, rather, whether technology has established indications for surgery where none existed before. Distal radius fractures are but one example. I hesitate to even mention the scores of biologics that reps attempt to show me under the guise of cash-pay “regenerative medicine.”
Several studies, limited in scope and often with methodological limitations, are often touted to suggest that those over the age of 65 can tolerate significant, if not profound, malunion without significant decline in functional outcomes. Are these studies suggesting that our technology driven ability to fix every fracture represents a waste of time and money, or even the triumph of surgical hubris over ethical principles and “primum non nocere”?
I think of several of my mentors and now colleagues are spry and athletic well past the age of 70, most still operating, many still performing microsurgery, one of whom still cycles a 7mi course through rolling hills and urban traffic to and from work each morning in rain, snow or Washington summer heat. How well would they tolerate a centimeter of shortening, 25 degrees of dorsal angulation or a coronal split with significant gapping? How well would they tolerate even a moderate loss of rotational motion?
The irony is that, despite over 200 years of study (Abraham Colles published in 1814), we have yet to fully understand these complex fractures and are still unable to predict outcomes based on injury films, post-reduction films or even post-surgical radiographic appearance. We struggle, or at least should struggle, to identify those patients who would benefit from fixation.
Our outcome measures lack the responsiveness to tease out subtle degradations in function, and perhaps this is due to our infinite adaptability and ability to roll with life’s punches and accept a slightly impaired level of function. Is that what allows older patients to tolerate malunion without measurable worsening of function, or is it our inability to really measure and quantify function? These are not easy questions. Can we chalk up a lack of significant differences to the inherent limitations of the DASH, the MHQ, the PRWE? Should we return to more objective measures of function such as simple range of motion and grip strength, or – even more shocking in the age of patient-reported outcomes – the physician’s subjective assessment of the patient’s function, Gartland and Werley, “Excellent, Good, Fair, Poor” etc? Perhaps we are hiding behind the veil of distance and detachment represented by objective criteria and patient-reported outcomes. Perhaps a return to subjective rating would be subtler, more honest.
The problems inherent in selection of outcome measures are just as significant as the conflation of chronological age with physiological age. When designing studies, we have to make arbitrary decisions, guided by review of what came before and current trends, by the predilections of our mentors and colleagues and editors, and by a pragmatic assessment of what can be accomplished with limited resources. Selection of outcome measures is often guided by what is easy to administer and easy to measure. But there is no accepted way of evaluating someone’s physiological age independent of their chronological age.
This is an area where little work is being done. Patient reported outcomes hinge upon the patient’s expectations of function recovery and perception of functional demands. Is our aged baby boomer population and its notoriously high expectations eventually going to skew our results? As financial pressures force the elderly to work longer, will our sense of what “elderly” means change profoundly? Even if we answer these questions, we still don’t know whether fixation of most moderately displaced fractures will lead to appreciably better outcomes, and our literature still fails to guide us clearly. As I ponder whether each radius actually needs to be fixed, I think about the last fifty years of orthopaedic progress and wonder whether the next fifty years will finally allow us to answer these seemingly basic questions.