When Not to Attempt Closed Reduction of Distal Radial Fractures Without Joint Involvement
Closed reduction should not be attempted in distal radial fractures with postreduction radial shortening >3 mm, dorsal tilt >10°, or when there is significant displacement that cannot be adequately reduced. 1
Radiographic Parameters That Indicate Surgical Fixation
The American Academy of Orthopaedic Surgeons (AAOS) guidelines provide specific parameters for when closed reduction is likely to fail and surgical fixation should be considered instead:
- Radial shortening >3 mm
- Dorsal tilt >10°
- Significant displacement that cannot be adequately reduced
- Unstable fracture patterns likely to lose reduction
Clinical Scenarios Where Closed Reduction Should Be Avoided
1. Failed Initial Reduction
- When an initial closed reduction has already failed to achieve acceptable alignment
- Evidence shows that re-reduction attempts have limited value and may delay definitive treatment
- A study found that patients who underwent re-reduction were more likely to require surgical intervention (34.3%) compared to those who had a single reduction (14.1%) 2
2. Age-Related Considerations
- In patients under 65 years, re-reduction attempts led to surgery in 49% of cases versus 21% in those with single reduction 2
- While the AAOS guidelines are inconclusive regarding surgical versus nonsurgical treatment in patients >55 years, the quality of reduction remains important 1
3. Predictors of Reduction Failure
- Comminution at the fracture site
- Significant initial displacement
- Osteoporotic bone
- Unstable fracture patterns (dorsal comminution)
Monitoring Post-Reduction
If closed reduction is attempted:
- All patients should receive a postreduction true lateral radiograph to assess distal radioulnar joint (DRUJ) alignment 1
- Ongoing radiographic evaluation should continue for 3 weeks and at cessation of immobilization
- Patients with unremitting pain during follow-up should be reevaluated for potential loss of reduction 1
Alternative Treatment Approaches
When closed reduction is not appropriate:
- Surgical fixation options include volar plating, external fixation, or percutaneous pinning
- The AAOS guidelines do not recommend any specific surgical method over others 1
- For minimally displaced fractures, removable splints may be an option 1
Common Pitfalls to Avoid
- Attempting multiple reductions when initial reduction fails - this may delay definitive treatment and lead to worse outcomes 2
- Failing to obtain proper radiographic views to assess reduction quality
- Not recognizing associated injuries (DRUJ instability, carpal ligament injuries)
- Inadequate immobilization after reduction (rigid immobilization is preferred over removable splints for displaced fractures) 1
Remember that the goal of treatment is to optimize functional outcomes and reduce complications. When closed reduction is unlikely to achieve or maintain acceptable alignment, early consideration of surgical options is warranted to improve morbidity, mortality, and quality of life outcomes.