From the Guidelines
Management of an incomplete fracture of the distal radial metaphysis with dorsal angulation typically involves closed reduction followed by immobilization in a cast, with consideration of surgical intervention if the angulation exceeds 10-15 degrees in adults or 20-30 degrees in children, or if closed reduction fails, as supported by the American Academy of Orthopaedic Surgeons (AAOS) and American Society for Surgery of the Hand (ASSH) clinical practice guideline summary management of distal radius fractures 1.
Initial Treatment
The initial treatment should begin with adequate pain control using analgesics such as ibuprofen (400-600mg every 6 hours) or acetaminophen (500-1000mg every 6 hours).
- For the reduction, the clinician should apply longitudinal traction followed by pressure on the dorsal aspect of the distal fragment to correct the angulation.
- After reduction, a well-molded long arm cast (extending from below the elbow to the metacarpophalangeal joints) should be applied with the wrist in slight flexion and ulnar deviation for 4-6 weeks, depending on the patient's age and healing progress.
Considerations for Specific Patient Groups
- For children, who have greater remodeling potential, 3-4 weeks may be sufficient.
- For patients under the age of 65, operative fixation is recommended for those with post-reduction radial shortening >3mm, dorsal tilt >10 degrees, or intra-articular displacement or step-off >2mm, as supported by the AAOS and ASSH clinical practice guideline summary management of distal radius fractures 1.
Monitoring and Follow-up
- Weekly radiographs should be obtained for the first 2-3 weeks to ensure the fracture remains properly aligned, as loss of reduction can occur.
- Patients should be instructed to keep the extremity elevated, monitor for signs of compartment syndrome (increasing pain, paresthesias, pallor), and perform active range of motion exercises of the fingers to prevent stiffness.
Surgical Intervention
- If the angulation exceeds 10-15 degrees in adults or 20-30 degrees in children, or if closed reduction fails, surgical intervention with percutaneous pinning or open reduction may be necessary, as supported by the AAOS and ASSH clinical practice guideline summary management of distal radius fractures 1. The AAOS and ASSH clinical practice guideline summary management of distal radius fractures provides moderate evidence to support treatment of non-geriatric patients and strong evidence that operative fixation does not lead to improved long-term patient reported outcomes relative to non-operative treatment in geriatric patients 1.
From the Research
Management of Incomplete Fracture of the Distal Radial Metaphysis with Dorsal Angulation
- The management of incomplete fracture of the distal radial metaphysis with dorsal angulation can be challenging, and various treatment options are available 2, 3, 4, 5, 6.
- A study published in the Journal of Children's Orthopaedics found that loss of reduction is common in patients with isolated distal radial metaphyseal fractures and intact ulnas, and that initial angulation in the coronal plane and post-reduction translation in the coronal plane are independent predictors for loss of reduction 2.
- Another study published in the Journal of Bone and Joint Surgery found that the use of a distraction plate can be an effective technique for treatment of fractures of the distal end of the radius with extensive metaphyseal and diaphyseal comminution 3.
- A prospective, randomized controlled trial published in the Journal of Bone and Joint Surgery found that the use of a percutaneous Kirschner wire to augment the reduction of the fracture in children with completely displaced metaphyseal fractures of the distal radius is a safe and reliable way of maintaining alignment of the fracture 4.
- A study published in the European Journal of Orthopaedic Surgery and Traumatology found that in adolescents, metaphyseal distal radius fractures have a higher risk of early re-displacement when not reduced in theatre, but both casting and fixation resulted in similar final angulation 5.
- A study published in the Journal of Bone and Joint Surgery found that the annual incidence of overriding distal metaphyseal radial fractures in patients under 16 years old was 1.42 per 10,000 population, and that opioids, local and general anesthesia, hospital admission, and secondary interventions can be avoided in prepubescent patients by casting these fractures in an overriding position while the patient is in the emergency department 6.
Treatment Options
- Closed reduction and casting 2, 4, 5
- Percutaneous Kirschner wire fixation 4
- Open reduction internal fixation 3, 5
- Distraction plate 3
- Manipulation under anesthesia (MUA) and cast in theatre 5