What are the surgical interventions for a distal radius (radius bone) fracture?

From the Guidelines

Surgical intervention for distal radius fractures is recommended when there is significant displacement, instability, intra-articular involvement, or failure of closed reduction, particularly in non-geriatric patients (less than 65 years of age) with post-reduction radial shortening >3mm, dorsal tilt >10 degrees, or intra-articular displacement or step-off >2mm 1. The primary surgical options include open reduction and internal fixation (ORIF) with volar locking plates, percutaneous pinning with Kirschner wires, external fixation, or a combination of these techniques.

• Volar locking plate fixation has become the preferred method for most unstable fractures as it provides stable fixation, allows early mobilization, and has shown good functional outcomes.
• Surgery is typically performed under regional or general anesthesia, with a volar approach being most common for plate fixation. Following surgery, patients usually wear a splint for 1-2 weeks, followed by progressive range of motion exercises.
• Physical therapy should begin around 2-6 weeks post-surgery, focusing on wrist and finger mobility, then strengthening. However, the evidence to support the use of routine supervised hand therapy for improving outcomes is inconsistent, and it is possible that specific subsets of patients may benefit from supervised hand therapy 1. Complications to monitor include hardware irritation, tendon rupture, infection, and complex regional pain syndrome. The use of arthroscopic assistance for evaluation of the articular surface during operative treatment of distal radius fractures is not supported by moderate evidence, as it has not been shown to improve outcomes 1. Surgical intervention is justified by the need to restore anatomical alignment, articular congruity, and radial length, which are critical for preserving wrist function, grip strength, and preventing post-traumatic arthritis. The decision for surgery should consider the patient's age, activity level, bone quality, and fracture characteristics, with a patient-centered discussion to better understand an individual patient’s values, preferences, and functional demand to inform appropriate decision-making 1.

From the Research

Distal Radius Fracture Surgical Intervention

• Distal radius fractures are a common clinical problem, particularly in older white women with osteoporosis 2
• The management of distal radius fractures should consider the severity of the fracture, desired functional outcome, and patient comorbidities 3
• Surgical management options include:
  • Closed reduction and application of a cast
  • Percutaneous K-wires
  • Open reduction and internal fixation with plates
  • External fixation 3
• A randomized study of 50 patients found that open reduction and internal fixation resulted in better grip strength and range of motion compared to external fixation 4
• A systematic review and meta-analysis of comparative clinical trials found that open reduction and internal fixation (ORIF) yielded significantly better functional outcomes, forearm supination, and restoration of anatomic volar tilt compared to external fixation 5
• Another meta-analysis of randomized controlled trials found that ORIF with plate fixation resulted in lower DASH scores, better restoration of radial length, and reduced infection rates compared to external fixation 6

Comparison of Surgical Methods

• External fixation and ORIF are both viable surgical alternatives for unstable distal radius fractures 5
• ORIF tends to have less malunions than external fixation 4
• External fixation resulted in better grip strength and wrist flexion in some studies 5
• The choice of surgical method should be based on individual patient characteristics and fracture patterns 2, 3

Outcomes and Complications

• Surgical methods are usually associated with better anatomical appearance after fracture healing, but there is inadequate evidence to confirm that these result in better functional and clinical outcomes for patients 2
• Common complications of distal radius fractures include median nerve compression, tendon rupture, arthrosis, and malunion 3
• The risk of complications and reoperation should be considered when choosing a surgical method 6