Long term Results of Conservative Treatment of Distal Radius Fractures in elderly, above the age of 70 years.

Abstract

Introduction

In this study super elderly patients of distal radius fracture trated conservatively   were examined at 1 year  post injury and then reevaluated after a median of 14 (range 12 to 16) years.

Materials and Methods

The study enrolled 64 residents of Sindhudurg who were treated for distal radius fractures by the author between 1 January 2008 and 31 December 2011 at the Government District Hospital Sindhudurg. Out of this 48 (75%) patients attended long term follow-up clinic which was conducted in the Orthopaedic Department between 1 January to 31 May 2022, providing long-term assessment after a mean of 14 years (range 12 to 16 years ) of distal radius fracture. This analysis focused on 48 participants aged over 70 years, recruited as part of an ongoing longitudinal investigation and were  assessed for  clinical, radiographic, and functional outcomes at the end of one year after distal radius fracture . All participants were managed by a single surgeon  non-operatively in group A with below cast in 22 (45.8%) and above elbow cast with fore arm in supination 26 (54.2%) group B during 2008–2011 and subsequently followed for reevaluation 12–16 years (mean 14 years). The right wrist was affected in 28 cases (58.3%). The sample comprised 32 (66.7%)  men and 16 (33.3%)  women, with a mean age of 77 years (range 70–98 years).

Results

The mean patient-rated wrist evaluation (PRWE) score was 12 (SD 17, range 0–96). The mean EQ-VAS score was 81.2 (range 25–100; 95% CI 76–84). Scores were lower among participants managed in group B compared with group A (p = 0.03). At long-term follow-up, mean ± SD PRWE values for the group A 13.5 ± 29.6, and  in the   group  B were 7.3 ± 12.5.   Participants of group B treated with above elbow cast with fore arm in supination demonstrated superior functional outcomes and greater satisfaction (mean ± SD 11.5 ± 28.0 vs. 7.3 ± 12.9; p = 0.5). Overall, 12 (46.2%) participants of group B  reported being highly satisfied with their long-term outcomes, compared with 5 (22.7 %) in   group A . Conversely3(13.6%) were very much dissatisfied in   group A as against 1(3.8%) from group B   (p > 0.001).

Conclusion

In this cohort of older adults with distal radius fractures, of group Btreated with above elbow cast with fore arm in supination  management was associated with better long-term functional outcomes, greater patient satisfaction, and improved daily living activities compared with group A patients treated by below elbow cast with fore arm in pronation .

Introduction

Since Abraham Colles’ first description of distal radius fractures in 1814,(1) numerous studies have been published on this subject. (1) However, reviews of the literature regarding the outcomes of non-operative management show inconsistent results.(2) Distal radius fracture is the most common upper extremity fracture in individuals aged 65 years and older, with an annual incidence of 8 to 10 per 1,000 person-years in this population.(3) These injuries typically result from ground-level falls while walking and often occur in older adults who remain relatively healthy, active, and functionally independent.(4)

For fractures that are stable and anatomically reduced, closed reduction followed by below-elbow plaster immobilization is the standard approach. Historically, even displaced but stable fractures have been managed non-surgically.(5) Reported clinical and functional outcomes after non-operative management of distal radius fractures of varying types and displacements differ considerably, with unsatisfactory results documented in 9–32% of cases at short-term follow-up.(6)

Unstable distal radius fractures have traditionally been managed by closed reduction and the long-established technique of below-elbow plaster splinting with the forearm in pronation and ulnar volar flexion.(7) However, such fractures are prone to redisplacement, usually within the first two weeks,(8) and remanipulation is often required to maintain an acceptable alignment.(9) The long-term prognosis of manipulated fractures has been less well documented.(10)

Closed reduction and cast immobilization remain widely used for older adults. Several authors have reported clinical and functional outcomes of non-operative management at 1 to 2 years post-fracture,(11) while others have examined results after 3 to 5 years.(12) Long-term studies are relatively rare,(13) and the recovery of grip strength and wrist range of motion over extended follow-up remains insufficiently explored. Nevertheless, prior research indicates that older, low-demand patients often achieve acceptable outcomes despite frequent radiographic displacement. (14)

The specific aim was to review the long-term outcomes of 48 distal radius fractures in patients over the age of 70 years, all of which were managed non-operatively. The additional objectives of the present study were: (1) to determine changes in wrist mobility and grip strength over time at one year and at long-term follow-up (14 years; range 12–16 years) after treatment of distal radius fractures, and (2) to assess whether clinical and functional outcomes correlate with radiographic evaluations performed initially at one year and at final long-term follow-up.

Methods

This study included 64 participants between January 1, 2008, and December 31, 2011 aged over 70 years with distal radius fractures, recruited into an ongoing longitudinal study to evaluate long-term outcomes. All were managed by a single surgeon at the Government District Hospital, Oros, Sindhudurg, between 2008 and 2011. At that time, this hospital was the only public facility in the district offering both non-operative and operative management of distal radius fractures free of cost, under the care of a full-time orthopedic surgeon.

To investigate the long-term outcomes of non-operatively treated distal radius fractures, a new follow-up was conducted on the same participants previously studied. Since no significant differences were found among the initial treatment subgroups, the cohort was considered homogeneous, with all participants managed non-operatively one year after the fracture. After 12 to 16  years, 48 participants (75.0%) from the original cohort were successfully identified and attended .

Of the initial 64, 11 participants (17.2%) had died, 4 (6.3%) were too unwell to attend, and 1 (1.7%) was unable to travel. Thus, 48 (75.0%)  participants attended the follow-up evaluation, conducted at a mean of 14 years post-injury (range 12–16 years). . The cohort comprised 16 women (33.3%) and 32 men (66.7%), with ages ranging from 70 to 98 years (mean 77 years). Frykman classification system has been adopted which was found to be quite comprehensive and well suited for this study purpose. (15)  All participants provided informed consent. The original study and this long term follow up study were approved by the Ethical Committee of the Government District Hospital, Sindhudurg.

Using Frykman’s classification , fractures were distributed as follows: Type I, 3  (6.3%); Type II, 4  (8.3%); Type III, 7  (14.6%); Type IV, 6 (12.5%); Type V, 8  (16.7%); Type VI,   (14.6%); Type VII, 5   (10.4%); and Type VIII, 8 (16.7%). Articular involvement was observed in 28 participants (58.3%). Of these, 21  (43.8%) were dorsally displaced, 9 (18.8%) volarly displaced, and 13 (27.1%) showed severe comminution.

Follow-up assessments were carried with invitations sent via postcards and telephone messages. Inclusion criteria were local residents over 70 years of age with   unstable displaced closed fractures requiring reduction. with regular follow up for one  year  are only included in this study. All patients who met these inclusion criteria were called upon physically to be present at special review clinic attended by author for examination by sending post cards. This follow up clinic was conducted in orthopaedic department from 1st January 2022 to 31st May 2022 with long term follow of 10-14 years after this original study period of 2008 to 2011.  Exclusion criteria included undisplaced fractures, open fractures, rheumatoid arthritis, bilateral distal radius fractures, upper arm injuries, compound fractures, and inability to attend follow-up due to severe comorbidities.

Participants were divided into two groups: Group A 22 (45.8%) treated with below-elbow casts with fore arm  in pronation, with wrist in palmar flexion and ulnar deviation  Group B  26 ( 54.2%) treated with above-elbow casts in supination, with wrist in palmar flexion and ulnar deviation. In Group B, casts were changed after two weeks to below-elbow casts in supination with the wrist in a neutral position. Immobilization ranged from 4 to 10 weeks (mean 5 weeks).

Outcomes were assessed using the modified Gartland and Werley demerit point system as modified by Sarmiento er al. classifying results as excellent (0–2), good (3–8), fair (9–20), or poor (≥21). ,(16) Radiographs were reviewed at multiple time points: pre-reduction, immediately after reduction, at 14 days (slipped position), after re-manipulation, four weeks post re-manipulation (union), at 8 and 12  weeks at 6 months , one year, and at the final  14-year follow-up (range 12 to 16 years). Detailed physical examination was done by the author along with wrist radiographs.  Radiographic evaluation at final follow-up assessed volar tilt angle, radial inclination, and ulnar variance, as described by Goldfarb with the modified technique of Steyers & Blair.(17) Measurements were taken by a senior radiology technician blinded to the participants’ clinical outcomes and verified independently by a radiologist. Functional evaluation included wrist and forearm range of motion, grip strength, pain assessment, and disability using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. The DASH contains 30 items, scored 0–100, with higher scores reflecting greater disability.  Data analyzed in the original study of 2008 to 2011 obtained from clinical records of Govt. District Hospital. The selection of distal radius fracture patients in this report was based solely on the final diagnosis mentioned in case paper as well as the fracture treatment registered by the treating doctor. Radiography confirmed each diagnosis of distal radius fracture.  Additional parameters included radial angulation, ulnar variance (ulna plus), and volar tilt. Osteoarthritis was graded at final follow-up as: grade 0 (none), grade 1  minor osteophytes , grade 2 (moderate  changeo sclerosis, osteophytes, joint-space narrowing), and grade 3 (severe changeo cysts, near-complete obliteration of joint space). (18).

Wrist range of motion (flexion, extension, radial and ulnar deviation, pronation, and supination) was measured with a goniometer. (19) Grip strength was recorded using a dynamometer, expressed as a percentage of the contralateral side, with a 10% correction applied for hand dominance in right-handed participants.(20) Subjective and objective outcomes were scored using the modified Gartland and Werley system.

Participants were clinically, functionally, and radiographically assessed at 2 weeks, 4 weeks, and 6 months. Grip strength and wrist motion were measured at 2, 3, 6 and 12 months. Five visual analog scales (VAS) were used, each 100 mm in length, to assess: (1) pain at rest, (2) pain with light activity, (3) pain with heavy activity, (4) wrist-hand function in light activities, and (5) wrist-hand function in heavy activities. The patients were asked to assess discomfort, expressed as 0 no problems to 100 worst possible discomfort.

At the final follow-up, grip strength was reassessed by the same staff nurse who had performed the original evaluations, at one year using a Martin vigor meter. displaying the strength in kPa each hand was registered  In the analyses, grip strength was defined as the grip strength of the injured hand measured on each separate occasion, divided by the strength of the opposite hand measured at the same time.  To compensate for hand dominance, 10% was added to the left side for right-handed patients; for left-handed patients, no correction was made.(21) The wrist range of motion was measured with an angle caliper. The maximal degrees of flexion, extension, pronation, supination, radial deviation and ulnar deviations were determined for each wrist.   The sum of flexion and extension is expressed in percentage of the opposite wrist measured at the same visit. Because this study reports long-term outcome of distal radius fracture   , the analysis regarding wrist motion and grip strength includes only patients who had not sustained a distal radius fracture of the contralateral wrist at any time. Motion was analyzed using the GOBC score, expressed as the percentage of the contralateral wrist. (22)

Functional outcomes were assessed using the Patient-Rated Wrist Evaluation (PRWE), a 15-item questionnaire measuring wrist pain and disability in daily living activities. Scores range from 0 (no pain/disability) to 100 (severe pain/disability). Health-related quality of life was evaluated with the EQ-5D questionnaire, which assess mobility, self-care, daily activities, discomfort, and anxiety, generating a utility score between –0.33 and 1, with lower scores indicating poorer quality of life. The valid and reliable patient rated hand wrist functional outcomes and end results with sequential change in quality of life proposed by the author are also measured.

Statistical Analysis

Data were analyzed using SAS version 8.2. Categorical variables were expressed as frequencies and percentages. Summary statistics were used to describe participant characteristics and compared between group A  and  groups B . PRWE, VAS, EQ-5D, and functional outcomes were compared by age, sex, hand dominance, treatment type, and Frykman classification using Student’s t-test and one-way ANOVA. Multiple linear regression was applied to identify associations between treatment modality and outcome scores. All analyses were conducted using SPSS, with statistical significance set at p < 0.05. Were considered statistically significant. Statistical analysis of these data (according to the formula: n = [ZY2 pq N]/[N ~ I] dZ + z2 pq) shows the sample significance to be 95%.

Results

Considering  the participants’ subjective, objective and functional  evaluations, the outcomes were notably poorer in Group A: Excellent in 5  (22.7%), Good  10 (45.5%), Fair  4 (18.2%), and Poor   3 (13.6%). In Group B, the distribution was: Excellent 12 (46.2%), Good 11 (42.3%), Fair 2 (7.7%), and Poor 1 (3.8%).

In some cases, anatomical reduction could not be achieved despite repeated attempts, and the results were accepted as such. At follow-up, abnormal values were noted in 4 (18.2%) for radial deviation and 3 (13.6%) for volar tilt (Table 1). Secondary displacement occurred in 6 participants (27.3%) in Group A, particularly in the dorsal direction, suggesting that dorsal comminution had a significant impact on quality of sagittal plane reduction. No statistically significant correlation could be found between loss of reduction and type of fracture according to Frykman’s classification. Unexpectedly, in some participants 3 (13.6%) radial deviation and volar tilt had increased rather than decreased. No significant correlation was found between loss of reduction and fracture type by Frykman’s classification. However, unsatisfactory results were more frequent when radial deviation was <5° (100% fair/poor outcomes) and dorsal tilt >15° (50%). In general, abnormal values were more common in Group A with fair or poor outcomes compared to Group B (P> 0.001) .

Radiocarpal osteoarthritis was observed in 14 (63.6%) in Group A and 6 (23.1%) in Group B at the final follow-up, with 32% of these cases associated with fair to poor outcomes. Residual finger stiffness was noted in both groups. Evidence of compressive neuropathy of the median nerve was found in 2 (9.1%) in Group A, with  1 (4.5%) of sensory deficit and 1 (4.5%) of combined motor and sensory deficit. No such complications were observed in Group B.

Final radial length correlated strongly with measurements at the ‘slipped’ position after 11 days (r = 0.70, p = 0.0001) and after remanipulation (r = 0.78, p = 0.0001). Final dorsal angulation correlated with initial values (r = 0.48, p = 0.07), at 11 days (r = 0.44, p = 0.02), and after re-manipulation (r = 0.58, p = 0.002). The degree of osteoarthritis correlated positively with age (r = 0.39, p = 0.03).

The analysis of ulnar variance demonstrated significant differences in dorsal angulation and radial length across time points (p < 0.0001). Radial length improved significantly after the first reduction (p < 0.001), after remanipulation (p < 0.001), and at follow-up (p = 0.009) compared to baseline deformity (Figure 2). Dorsal angulation was significantly reduced after the first reduction (p < 0.001), at the slipped position (p = 0.006), after remanipulation (p < 0.001), at union (p < 0.001), and at follow-up (p < 0.001).

At final follow-up, mean (SD) radial angulation was 22 ± 5°, and mean ulnar variance was 3 ± 2 mm. Total wrist motion correlated negatively with ulnar variance (r = –0.61, p = 0.003), while grip strength correlated negatively with the severity of osteoarthritis (r = –0.51, p = 0.03). The demerit point score showed strong linear associations with pain (r = 0.82, p = 0.002) and with total wrist motion (r = –0.63, p = 0.002). Correlations were also observed with initial radial length (r = 0.59, p = 0.004) and dorsal angulation (r = –0.50, p = 0.03). Total wrist motion correlated with radial length both initially (r = 0.49, p = 0.008) and at the slipped position (r = 0.57, p = 0.008).

VAS assessments at 14 years (range 12-16 years) showed no significant differences between age groups. Pain at rest and during light activities was minimal, but difficulties were reported during heavier activities  . No statistically significant differences in functional outcomes were found between participants aged 70–80 years, 81–90 years, and >91 years. In Group A, 6 (27.3%) and 4 (18.2%) were classified as excellent or good, compared to 11 (42.3%) and 10 (38.5%) in Group B within the same age ranges functionally. Participants aged 81–90 years and >91 years demonstrated slower recovery in both range of motion and grip strength compared to those aged 70–80 years. At one year post-fracture, Group A exhibited significantly reduced mobility and grip strength compared to Group B (p = 0.02). However, by the 14-year (range 12–16 years), follow-up  both groups had regained comparable levels of function. In the whole in both A & B groups of 48 patients with unilateral fractures, relative range of motion improved significantly faster than relative grip strength.(Table 2)

The mean patient rated wrist evaluation score was 12 (SD 17, range 0–96). No statistically significant differences were found in patient rated wrist evaluation score by sex (p = 0.2, p = 0.3) or fracture type by Frykman’s classification (p = 0.2, p = 0.3). Functional outcomes were also not significantly correlated with Frykman  fracture type. Similarly, patient rated wrist evaluation score did not differ significantly between decade-based age groups from 70 years onwards (p = 0.4). Participants managed with in group B above elbow plaster casts with fore arm in supination had lower scores, reflecting less pain and better wrist function, compared to those treated in group A by below elbow cast   (p < 0.01).

At long-term follow-up, the mean EQ-5D score was 0.86. Scores were significantly lower among participants aged 70 to 80 years compared to those over 81 (p = 0.04). The mean EQ-VAS was 81.2 (range 25–100; 95% CI 76–84), with no significant differences between age or sex subgroups. EQ-VAS scores were lower in participants managed   in group A  than in those of group B  (p = 0.03).

Self-rated long-term outcomes (mean ± SD) in group A were:   13.5 ± 29.6,  Comparable values for  group B were  7.3 ± 12.5 . Participants treated in group A reported lower satisfaction and poorer outcomes overall, with statistically significant differences (p > 0.001). In contrast,  participants showed better functional results and greater satisfaction (mean ± SD 11.5 ± 28.0 vs. 7.3 ± 12.9; p = 0.5) in group B Overall 12(46.2%) elderly patients treated by above elbow cast in supination were very much satisfied with the eventual long term outcome of their distal radius fracture as against 5 (22.7%) treated by below elbow cast. Similarly 3(13.6%) were very much dissatisfied in A group as against 1 (3.8%) from   group B  (p > 0.001). Both values are statistically highly significant.

In this cohort, secondary displacement occurred in 7 (31.8%) in Group A and 1 (3.8%) in  participant Group B. These cases required remanipulation and recasting for four additional weeks. Remanipulation was generally performed when dorsal angulation exceeded 10° or radial shortening was >5 mm.(23) Factors such as patient age, occupation, and functional demands were considered in these decisions. At the time of injury, the mean age was 72 years (SD ± 15), and the mean interval before remanipulation was 11 days (range 7–15 days). Of the 48 participants, 8 (16.7%) underwent a follow-up study at a mean of 10.2 years, which included subjective, radiographic, and functional evaluations.

Discussion

The values of the three radiographic parameters studied—radial deviation, volar tilt, and dorsal tilt—were frequently found to be outside the normal range in this study in group A. Comparison of post-reduction and follow-up radiographs revealed that loss of reduction was common in group A than group B. However, significant radiologic deformities only corresponded to clinically unacceptable outcomes in cases with extremely abnormal values. (24) Despite this, fractures of the distal radius should not be underestimated, as long-term results following non-operative management may be less favorable than generally assumed. (25)

Literature suggests that majority of  distal radius fractures in older osteoporotic patients  are   extra-articular fractures, usually resulting in good functional outcomes. However, this present  study focused specifically on displaced, unstable distal radius fractures. Conservative treatment, such as casting or splinting which is often preferred in older adults sometimes  fails to adequately correct radial shortening and may result in pain, diminished function, or malunion. (26)

Management of distal radius fractures remains controversial. There is no consensus on whether fractures should be immobilized in pronation, supination, or an intermediate position, nor on the use of above- versus below-elbow casts. (27) Functional bracing in supination has shown improved outcomes in severely comminuted fractures. (28) Hence the  closed reduction and plaster casting remain the treatment of choice for most older adults. (29) A review of old literature on non-operative management on distal radius fracture achieved by numerous authors shows conflicting results: Gartland and Werley reported 31.7% unsatisfactory outcomes in 60 displaced fractures; Judet et al. reported 13.8% fair to poor outcomes in 247 cases; Castaing reported 18.8% in 440 fractures; Frykman, in 430 wrist fractures, found 25% unsatisfactory outcomes. More optimistic findings include Edward and Clayton (3.7% in 321 cases), Cassebaum (6% in 81 cases), and Mason (5% in 100 cases). Nonetheless, the more comprehensive reviews suggest that results are not entirely satisfactory, a conclusion echoed by Sarmiento and Cooney et al.(30)

The present study analysis of long-term follow-up (12–16 years, mean 14 years) revealed unsatisfactory outcomes in 7 (31.8%) participants in Group A and 3 (11.5%) in Group B. While these percentages are not very high considering the age group, they are notable given the frequency of these fractures.Radiologic deformities were only linked to poor outcomes in cases of severe abnormality. Radiocarpal osteoarthritis occurred in 18%, particularly after Type VII and VIII fractures. The authors emphasize that distal radius fractures should not be underestimated, as secondary displacement is common, and extreme radiographic abnormalities are associated with fair to poor outcomes.(31)

In this study, only low-energy fractures with comminution were included for re-manipulation and immobilization. The hypothesis was that this homogeneous group might achieve better anatomical and functional outcomes compared to unselected series. The results demonstrated significant improvement in anatomical alignment, particularly dorsal angulation, while functional outcomes were excellent or good in most cases. Early studies on Colles’ fractures reported that axial compression is more difficult to correct, a finding consistent with this study, though dorsal angulation improved significantly. (32)

Total wrist movements correlated negatively with ulna plus, and grip strength correlated negatively with radio carpal osteoarthritis. Other anatomical-functional correlations were not significant, supporting Roumen et al.’s findings that final anatomical alignment has limited correlation with functional outcome in older adults with displaced distal radius fractures.(33) Similarly, Stein et al. and Horne et al. reported that osteoporotic older adults tolerate residual deformities well, and clinical outcomes show low correlation with anatomical alignment.(34)

In this long term follow up study , the total pronation and supination correlated with initial radial length and dorsal angulation, and total motion correlated with initial and 11-day radial length (slipped position), confirming that initial radial shortening influences anatomical and functional outcomes in non-operatively treated distal radius fractures. From the participants’ perspective, final outcomes were largely determined by persistent pain and range of motion. (35)

The study concludes that selected super elderly with low-energy, displaced fractures may achieve improved anatomical outcomes after re-manipulation and plaster immobilization compared with initial deformity. Dorsal angulation improved significantly, though radial length did not, while functional outcomes were excellent or good in most cases. Initial fracture displacement was important in predicting final range of motion. (36)

A limitation of this study is that only 48 participants were available for long-term follow-up, limiting generalizability. Nevertheless, several findings are considered valid in this study : the time course of recovery in range of motion and grip strength, differences between 70 to 80 years  and super elderly participants, and the relationship between radiographic appearance and clinical outcome. The GOBC score was used to reduce bias, focusing only on relevant clinical and functional parameters (pain, functional status, range of motion, and grip strength) without influence from radiographic deformity.(37)

In this cohort, 7 (31.8%) in Group A and 3 (11.5%) in Group B had fair or poor outcomes at a mean of 14 years. Literature reports varying long-term results: at 10-year follow-up of 55 participants (mean age 60), 15% had fair or poor outcomes; in another 1.5–6-year follow-up of 289 participants, 13% were fair/poor by objective assessment and 20% by subjective assessment. (38) A 30-year follow-up of 76 young participants (mean age 31 years ) found 81% with no difference between injured and contralateral wrist, though 17% had a contralateral fracture. (39)

Conflicting reports exist regarding correlation between radiographic appearance and functional outcomes. While radiographic irregularity has been linked to osteoarthritis and disability in older participants , this study found no clear association. No correlation was found between functional outcome and Frykman fracture type. However, radiographic displacement did correlate with GOBC scores. The fair or poor outcomes were associated with greater initial and residual displacement. (40) Ten-year follow-up studies support that initial and residual radial shortening, not dorsal angulation, correlates with function. Radial shortening is a major risk factor for late instability and unsatisfactory results.(41) Pronounced initial displacement predisposes to residual displacement despite initial successful reduction, reflecting true fracture instability. (42)

Closed reduction and plaster treatment improved dorsal angulation and radial inclination but not to normal values, with persistent some deformity remaining. Radial shortening was not corrected, consistent with other studies. Grip strength is a sensitive indicator of wrist function recovery, and though it improves over time, maximum recovery occurs years after fracture. (43) Literature supports gradual recovery: 68% grip strength at 1 year, 84% at 34 months in older adults, and 94% at 5 years in mixed-age populations. (44) This study found grip strength recovery slower than range of motion, particularly in super older adults (81–98 years) compared to 70–80 years.

Conclusion 

The closed reduction and plaster casting positively influenced dorsal angulation and radial inclination, though not to normal values, with functional outcomes generally good to excellent. Recovery of grip strength lags behind range of motion, and super elderly between 70 to 80 years of age  recover more slowly than elderly  counterparts with age between 81 to 98 years. This study did not show a correlation between increase in disability and decrease in wrist range of movement , so also  between radiological  measures and functional scores. Super elderly patients treated with above elbow cast with fore arm in supination  had over all long term better functional out come and patient satisfaction with improved patient reported daily living activities than patients treated by below elbow cast with fore arm in pronation.

Table 1

 Range of movements in Group A and B at one year and at final follow up

Table  2

Rage of movements of radiocarpal and distal radio ulnar joints.         

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