What is the treatment for an isolated radial shaft fracture?

Treatment of Isolated Radial Shaft Fractures

For isolated radial shaft fractures, open reduction and internal fixation (ORIF) using plates is the gold standard treatment for displaced fractures, while non-displaced or minimally displaced fractures can be managed with cast immobilization for 3 weeks. 1, 2

Assessment and Classification

When evaluating a radial shaft fracture, consider:

• Displacement status (displaced vs. non-displaced)
• Angulation degree
• Location of fracture (proximal, middle, or distal third)
• Associated injuries (especially distal radioulnar joint involvement)
• Patient factors (age, functional status, comorbidities)

Treatment Algorithm

Non-displaced or Minimally Displaced Fractures

1. Initial immobilization: Sugar-tong splint
2. Definitive treatment: Short-arm cast for 3 weeks 3
   • Research shows 3 weeks of immobilization leads to better functional outcomes compared to 5 weeks
   • Patient-reported outcomes are significantly better with shorter immobilization periods (PRWE scores of 5.0 vs. 8.8 points, p=0.045)
   • No increased risk of secondary displacement with shorter immobilization

Displaced Fractures

Surgical management with ORIF is indicated for:

• Fractures with >3mm radial shortening
• Fractures with >10° dorsal tilt
• Significantly displaced fractures 4

Surgical Approach Options:

1. Lateral approach 2:

   • Advantages: Simpler approach with lower operative complexity
   • Avoids risk to posterior interosseous nerve and radial artery
   • Mean operative time: 37.5 minutes for isolated radius fractures
   • Good exposure of middle third of radius
   • High union rates (100% in studied cases)

2. Traditional approaches:

   • Dorsal approach (risk to posterior interosseous nerve)
   • Volar approach (risk to radial artery and branches)

Post-surgical Immobilization:

• Either removable brace or traditional cast can be used 5
• Similar quality of recovery between both options
• Brace group may experience more pain in first 24 hours post-surgery
• Brace offers advantage of easier hygiene and adjustability

Special Considerations

1. Distal third fractures: Higher rates of distal radioulnar joint (DRUJ) involvement (30.7%) requiring DRUJ fixation 6

   • Consider DRUJ assessment in all radial shaft fractures, particularly distal third

2. Risk factors for complications 6:

   • Dependent functional status (OR = 6.78)
   • Older age (50-69 vs <50) (OR = 2.73)
   • ASA ≥3 (OR = 2.45)

3. Risk factors for readmission 6:

   • Male sex (OR = 12.76)
   • Older age (OR = 4.99)

Follow-up

• Radiographic evaluation at 3 weeks and at cessation of immobilization 4
• Monitor for secondary displacement
• Assess for median nerve injury, which can complicate distal radius fractures 1

Common Pitfalls

1. Missing associated DRUJ injuries, especially in distal third fractures
2. Prolonged immobilization leading to worse functional outcomes
3. Inadequate fixation resulting in nonunion or malunion
4. Failure to recognize nerve injuries, particularly median nerve in distal fractures

By following this algorithm and considering the specific characteristics of the fracture, optimal outcomes with minimal complications can be achieved for patients with isolated radial shaft fractures.