What is the acceptable degree of dorsal angulation in a distal radius fracture?

Acceptable Dorsal Angulation in Distal Radius Fractures

For non-geriatric patients (under 65 years), dorsal tilt greater than 10 degrees is an indication for surgical fixation, while patients over 65 years may tolerate greater angulation without surgical intervention. 1

Age-Based Recommendations

Non-Geriatric Patients (Under 65 Years)

• Dorsal angulation exceeding 10 degrees warrants surgical intervention 1
• Other surgical indications include:
  • Post-reduction radial shortening >3 mm
  • Intra-articular displacement or step-off >2 mm

Geriatric Patients (65 Years and Older)

• Greater dorsal angulation may be tolerated without surgical intervention
• Strong evidence shows that surgical fixation does not lead to improved long-term patient-reported outcomes compared to non-operative treatment in this age group 1
• Radiographic parameters may improve with surgery, but patient-reported outcomes show no significant difference

Biomechanical Considerations

• Dorsal angulation beyond 10 degrees can affect wrist biomechanics and function
• Research shows that with resistive loading, torque changes across the distal radioulnar joint (DRUJ) can occur with as little as 10 degrees of dorsal angulation 2
• Significant torque increases across the DRUJ occur with angulation exceeding 30 degrees 2

Clinical Implications

• Acceptable reduction parameters correlate with better functional outcomes
• For optimal functional results, dorsal angulation should be ≤10 degrees 3
• Conservative treatment can yield satisfactory results when dorsal angulation is maintained within acceptable limits

Treatment Decision Algorithm

1. Assess patient age:

   • Under 65 years: Maximum acceptable dorsal angulation is 10 degrees
   • 65 years and older: Higher degrees of dorsal angulation may be acceptable

2. Evaluate other radiographic parameters:

   • Radial shortening (>3 mm indicates surgical fixation)
   • Intra-articular displacement (>2 mm indicates surgical fixation)
   • Radial inclination loss (>9 degrees may affect function)

3. Consider functional demands:

   • Higher functional demands may warrant stricter reduction criteria
   • The age threshold of 65 years serves as a proxy for functional demand 1

Common Pitfalls to Avoid

• Failing to obtain adequate follow-up radiographs to detect early loss of reduction
• Not recognizing that fractures with preoperative dorsal angulation >20 degrees are at higher risk for loss of reduction during treatment 4
• Overlooking that fractures involving the distal radioulnar joint have significantly larger loss of reduction of dorsal angulation 4

Remember that while these guidelines provide general parameters, the 2022 AAOS guidelines emphasize that patient-centered discussions about values, preferences, and functional demands should inform decision-making beyond just chronological age 1.