A Comprehensive Review: Does Radiographic Alignment Predict Functional Outcomes in Elderly Patients With Distal Radius Fractures?

Distal radius fractures (DRFs) are among the most common fragility fractures in older adults (≥60 years). While radiographic parameters have traditionally guided management, their association with functional recovery in this population remains uncertain. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, we systematically reviewed randomized controlled trials (RCTs) and prospective and retrospective studies assessing radiographic alignment and functional outcomes in older adults with DRFs. Databases searched included PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus, with the last search on March 28, 2024. Studies were eligible if they enrolled patients with a mean/median age of ≥60, reported radiographic parameters, and measured outcomes using validated instruments (Disabilities of the Arm, Shoulder, and Hand (DASH), Patient-Rated Wrist Evaluation (PRWE), grip strength, range of motion (ROM)). A total of 416 records were screened; 23 studies (10 RCTs, two prospective cohort studies, seven retrospective comparative studies, four observational studies; sample size: 36-420 patients) were included. Operative management restored alignment more reliably than conservative care, yet these gains did not consistently translate into superior functional outcomes. Grip strength and ROM were more robust predictors of recovery, with associations persisting beyond 12 months. Articular step-off >2 mm was associated with worse outcomes in several studies. Across studies, short-term (≤6 months) surgical advantages in grip strength and ROM diminished at long-term (≥12 months). Effect sizes and 95% CI are presented where available. Quality assessment showed moderate to high risk of bias in several studies, though sensitivity analyses excluding high-risk-of-bias studies did not alter conclusions. Radiographic alignment alone is an inconsistent predictor of functional recovery in older adults with DRFs. In contrast, grip strength and ROM demonstrate stronger, clinically meaningful associations with patient-reported outcomes. Surgical fixation may accelerate early recovery, but long-term functional results are often comparable to conservative care. Future management should prioritize function-centered, individualized treatment strategies.