Conservative management is non-inferior to surgical treatment for distal radius fractures in elderly patients: a prospective non-inferiority study

Distal radius fractures are the most common upper extremity fracture in elderly patients, yet optimal treatment remains controversial. Current evidence supporting surgical superiority over conservative management is inconsistent. We hypothesized that conservative management is non-inferior to surgical treatment for functional outcomes at 12 months in patients aged over 60 years. This prospective observational non-inferiority study enrolled 88 patients (mean age 67.7 ± 6.1 years, 72.7% female) with AO 23 A or 23 C distal radius fractures at a tertiary care center between June 2022 and May 2024. Patients received conservative management (closed reduction and casting, n = 44) or operative treatment (surgical fixation, n = 44). Primary outcomes were DASH and PRWE scores at 12 months. Pre-specified non-inferiority margins were 10 points for DASH and 11.5 points for PRWE based on minimal clinically important differences. Analysis used Two One-Sided Tests with bootstrap validation. Groups were well-balanced at baseline. Conservative management was non-inferior for both outcomes: DASH mean difference − 2.2 (95% CI: -6.6 to 2.1, upper bound below margin of 10); PRWE mean difference − 3.0 (95% CI: -6.4 to 0.5, upper bound below margin of 11.5). Bootstrap analysis confirmed robustness. Propensity score matching (32 matched pairs) and three additional sensitivity analyses (IPTW, multivariable regression, doubly robust estimation) yielded concordant results confirming non-inferiority. Responder rates achieving minimal disability (DASH < 30) were 93.0% versus 86.0% ( p = 0.291). Complication rates were identical (13.6% each, p = 1.000). Hospital stay was significantly shorter with conservative management (1.2 ± 0.4 versus 2.1 ± 0.8 days, p < 0.001). Conservative management appears to achieve functional outcomes non-inferior to surgical treatment in elderly patients with distal radius fractures, with equivalent safety and shorter hospitalization. These findings support informed shared decision-making and may help guide treatment selection in this growing population. Therapeutic Level II.