Imaging the joint above and below: investigating the need for "completion imaging" in geriatric fragility distal radius fractures.

BACKGROUND: Distal radius fragility fractures (DRFFs) are common injuries in older adults following low-energy falls. While wrist radiographs are standard, additional “completion imaging” of the ipsilateral hand, forearm, and elbow is frequently obtained, though its diagnostic yield and clinical utility are poorly defined. This study aimed to evaluate the yield of completion imaging in DRFFs and identify risk factors for concomitant injuries outside the wrist. METHODS: A retrospective cohort study was conducted at a tertiary academic center from 2017-2024. Patients aged ≥50 years with radiographically confirmed DRFFs sustained from low-energy mechanisms were included. Demographic, clinical, fracture, and imaging data were abstracted. Completion imaging yield was defined as the proportion of patients with additional injuries detected, with 95% confidence intervals (CIs) calculated using Wilson’s method. Univariable analyses were performed to assess associations between patient factors and concomitant injuries, with statistical significance defined as p<0.05. RESULTS: A total of 188 patients met inclusion criteria. The median age was 77 years (interquartile range [IQR]: 71-86), and 90% were female. Most fractures were AO Foundation/Orthopaedic Trauma Association (AO/OTA) type 23A (47%) or 23C (30%). Concomitant injuries outside the wrist and forearm occurred in 51 patients (27%), most commonly hip or pelvic ring fractures (6%), followed by shoulder/clavicle (4%) and intracranial injuries (4%). Completion imaging was obtained in 179 patients (95%), with a low diagnostic yield of 3.8% for hand radiographs, 3.9% for elbow radiographs, and 0% for forearm radiographs. All additional injuries were clinically suspected. AO/OTA fracture pattern was significantly associated with concomitant injuries (p=0.04), whereas age, sex, mechanism, and ambulatory status were not (all p>0.05). CONCLUSIONS: Completion imaging in older adults with low-energy DRFFs demonstrated low diagnostic yield, with additional injuries identified only when clinically suspected. Forearm radiographs may offer limited value, while hand and elbow imaging should be targeted to patients with focal tenderness or communication barriers. Given that over one-quarter of patients had concomitant injuries, clinicians should remain vigilant beyond the wrist, and prospective studies with safety evaluation are needed to define optimal imaging strategies. LEVEL OF EVIDENCE: III, retrospective cohort study