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

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.