What degree of displacement requires reduction in a wrist fracture?

Wrist Fracture Reduction Thresholds

Wrist fractures require reduction when there is >2mm of articular step-off, >3mm of radial shortening, or >10 degrees of dorsal tilt to prevent long-term complications such as osteoarthritis and functional impairment. 1

Radiographic Parameters Requiring Reduction

Articular Surface Displacement

• Intra-articular step-off >2mm requires operative fixation to avoid long-term complications such as osteoarthritis 1
• This threshold applies regardless of patient age, though treatment approach may differ

Radial Parameters

• Radial shortening >3mm indicates need for reduction 1
• Dorsal tilt >10 degrees indicates need for reduction 1
• These parameters are particularly important in patients under 65 years of age

Age-Based Considerations

Non-Geriatric Patients (<65 years)

• Moderate evidence supports operative fixation for:
  • Radial shortening >3mm
  • Dorsal tilt >10 degrees
  • Intra-articular displacement/step-off >2mm 1
• These patients benefit more from anatomic reduction due to higher functional demands

Geriatric Patients (≥65 years)

• Strong evidence indicates surgical fixation does not improve long-term patient-reported outcomes compared to non-operative treatment 1
• While radiographic parameters may improve with surgery, patient-reported outcomes show no significant difference
• Consider functional demands rather than chronological age when making treatment decisions

Special Circumstances Requiring Immediate Reduction

• Vascular compromise: Emergent reduction needed when wrist pulses are absent or hand perfusion is decreased 2
• Severe displacement: Fractures with coronally oriented fracture lines, die-punch depression, or more than three articular fragments often require operative intervention 1
• Mallet injuries: Palmar displacement of the distal phalanx or interfragmentary gap >3mm indicates need for surgical fixation 1

Imaging Considerations

• Initial evaluation requires minimum 3-view radiographs (posteroanterior, lateral, and 45° semipronated oblique) 1, 2
• Consider fourth view (semisupinated oblique) for better visualization 2
• CT without IV contrast recommended when radiographs are equivocal, particularly for evaluating intra-articular extension 1, 2

Pitfalls and Caveats

• Inadequate reduction leading to malunion is a common complication 2
• Minimally angulated fractures (≤15 degrees) in children may not require manipulation due to excellent remodeling potential 3
• Long-term studies show that patients with more displaced fractures that heal with greater displacement have worse outcomes 4
• In elderly patients, studies show no significant difference in Patient-Rated Wrist Evaluation scores between surgical and non-surgical treatment at 12 months 5
• Complications of internal fixation can include tendon irritation (most common), carpal tunnel syndrome, and complex regional pain syndrome 6

By adhering to these thresholds for reduction, clinicians can optimize outcomes while avoiding unnecessary interventions, particularly in older patients where functional outcomes may be similar despite radiographic differences.