What is the recommended treatment for an angulated non-displaced distal radial bone fracture?

Treatment of Angulated Non-Displaced Distal Radial Fractures

For angulated non-displaced distal radial fractures, a three-week immobilization period with a cast is recommended as it provides equal outcomes with fewer functional limitations compared to longer immobilization periods. 1

Initial Assessment and Management

• Initial assessment should include radiographs to evaluate:
  • Degree of angulation
  • Presence of displacement
  • Associated injuries
  • Joint stability 2
• CT without IV contrast may be needed if radiographs are indeterminate to better visualize fracture morphology 2

Immobilization Approach

Type of Immobilization

• For non-displaced or minimally displaced fractures:
  • Rigid immobilization with a short-arm cast is appropriate 2
  • A splint is preferred initially if significant swelling is anticipated 2

Duration of Immobilization

• Three weeks of cast immobilization is recommended for non-displaced distal radial fractures 1
  • Research shows that 3-week immobilization leads to better functional outcomes compared to 5-week immobilization
  • Patients with 3-week immobilization demonstrated significantly better PRWE scores (5.0 vs 8.8 points) and QuickDASH scores (0.0 vs 12.5) after one year 1
  • Shorter immobilization does not increase the risk of secondary displacement 1

Positioning and Cast Application

• The wrist should be held in a position of gentle flexion and slight ulnar deviation 2
• Apply a well-molded cast with minimal padding to achieve optimal "cast index" (ratio of sagittal to coronal width should be less than 0.8) 3
• Three-point molding technique should be used to maintain proper alignment 2

Post-Immobilization Care

Rehabilitation Protocol

• Active finger motion exercises should begin immediately following diagnosis to prevent stiffness 2
• After cast removal:
  • Progressive range of motion exercises
  • A directed home exercise program 2
  • Wrist motion exercises performed 3 times daily 3
  • Consider a removable wrist splint for an additional 2-4 weeks if fracture line remains visible on radiographs 3

Follow-up Schedule

• Radiographs at 1 and 2 weeks post-immobilization to confirm maintained alignment 2, 3
• Full return to activities typically expected at 3 months 3

Complications to Monitor

• Watch for signs of:
  • Median nerve injury (assess sensation in thumb, index, and long fingers) 3, 4
  • Excessive immobilization risks: chronic pain, joint stiffness, muscle atrophy, and complex regional pain syndrome 2
  • Secondary displacement (rare with non-displaced fractures) 1

Special Considerations

• For elderly patients:
  • Evaluate for osteoporosis risk
  • Consider calcium and vitamin D supplementation
  • Assess fall risk factors 2
• Smoking increases nonunion rates and leads to inferior clinical outcomes 2
• Low-intensity pulsed ultrasonography (LIPUS) should NOT be used as it does not accelerate healing 2

Emerging Alternatives

• Removable splints are being studied as an alternative to casts for minimally displaced fractures, but evidence for their safety and effectiveness is still lacking 5