What is the treatment for an intra-articular fracture of the distal left radial metaphysis?

Treatment for Intra-articular Fracture of the Distal Left Radial Metaphysis

Surgical fixation is recommended for intra-articular distal radius fractures with postreduction radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement to optimize functional outcomes and reduce complications. 1

Initial Assessment and Indications for Surgery

When evaluating an intra-articular fracture of the distal radius, several radiographic parameters should be assessed:

• Radial shortening (>3 mm indicates instability)
• Dorsal tilt (>10° indicates instability)
• Intra-articular step-off or gap (any displacement)
• Comminution (indicates potential instability)

Treatment Algorithm

1. Initial Management:

   • Closed reduction and splinting as a temporary measure
   • CT scan to better evaluate the intra-articular component 1
   • Radiographic follow-up within 3 weeks of initial treatment

2. Definitive Treatment:

   • For fractures with maintained reduction and minimal displacement: rigid immobilization with casting 1
   • For fractures with significant displacement or instability: surgical fixation

Surgical Options

The evidence does not conclusively recommend one specific surgical method over another for intra-articular distal radius fractures 1. However, several options have demonstrated efficacy:

Open Reduction and Internal Fixation (ORIF)

• Volar plating: Provides early functional recovery and better early outcomes
  • Advantages: Better early functional outcomes, earlier return to function 2
  • Allows for early mobilization
  • Lower complication rates compared to dorsal plating 3

External Fixation with Supplemental K-wires

• Option for highly comminuted fractures
• May be combined with mini-open reduction techniques
• Acceptable functional outcomes in most patients, even with some secondary displacement 4
• Lower complication rates compared to dorsal plating 3

Important Considerations

• Age considerations: Evidence does not clearly favor surgical vs. non-surgical treatment in patients >55 years 1
• Arthroscopic assistance: Current evidence does not support routine use of arthroscopy during fixation of intra-articular distal radius fractures 1
• Associated injuries: Consider treatment of concomitant ligamentous injuries (SLIL, LT, TFCC) at the time of fixation 1

Rehabilitation

• For minimally displaced fractures treated non-surgically: removable splints may be used 1
• For displaced fractures treated non-surgically: rigid immobilization is preferred 1
• For surgically treated fractures: early mobilization can be considered, especially after volar plate fixation 2

Potential Complications to Monitor

• Secondary displacement (particularly in elderly patients with osteoporosis) 4
• Malunion
• Intra-articular incongruity
• Reflex sympathetic dystrophy/Complex regional pain syndrome
• Hardware-related complications

Key Pitfalls to Avoid

1. Inadequate reduction of articular surface: Failure to restore articular congruity can lead to post-traumatic arthritis
2. Insufficient fixation: Particularly in osteoporotic bone, may lead to secondary displacement 4
3. Delayed mobilization: When appropriate fixation is achieved, early mobilization improves functional outcomes 2
4. Overlooking associated soft tissue injuries: Consider ligamentous injuries that may require treatment 1

The choice between ORIF with volar plating and external fixation with percutaneous pinning should be based on fracture pattern, bone quality, and surgeon experience, with the understanding that volar plating may offer better early functional outcomes and potentially fewer complications than other techniques 2.