What is the treatment for a mildly displaced and dorsally angulated incomplete transverse fracture of the distal radial metadiaphysis?

Treatment for Mildly Displaced and Dorsally Angulated Incomplete Transverse Fracture of Distal Radial Metadiaphysis

The optimal treatment for a mildly displaced and dorsally angulated incomplete transverse fracture of the distal radial metadiaphysis is closed reduction followed by cast immobilization for 3-4 weeks with clinical and radiographic reassessment at 2-3 weeks. 1

Initial Management

1. Imaging Assessment

   • Standard radiographs are the initial imaging of choice to evaluate fracture morphology 1
   • In equivocal cases, CT without IV contrast can better visualize fracture details 1

2. Reduction Technique

   • Position patient supine with injured arm on image intensifier
   • Apply in-line traction to correct radial or ulnar translation
   • Hyperdorsiflex the wrist with traction applied to the distal fragment
   • "Walk" the distal fragment up and over while applying axial traction
   • Bring wrist from extension to flexion 2
   • Hold reduced wrist in gentle flexion and slight ulnar deviation

3. Post-Reduction Assessment

   • Obtain post-reduction fluoroscopy in anteroposterior and lateral views
   • Acceptable alignment parameters:
     • Dorsal angulation <15°
     • Volar tilt <20°
     • Radial inclination >15°
     • Ulnar positive variance <5 mm
     • Articular step-off <2 mm 3

Immobilization

1. Cast Application

   • Apply a long-arm cast by first applying a short-arm cast with a 3-point mold 2
   • Use minimal cast padding to achieve optimal "cast index" (ratio of sagittal to coronal width) of <0.8 2
   • Re-image wrist on fluoroscopy to confirm alignment

2. Duration of Immobilization

   • Average immobilization duration: 3-4 weeks 1
   • Clinical and radiographic reassessment at 2-3 weeks to evaluate healing progression 1
   • For children, consider splint instead of cast for minimally angulated fractures (equally effective with comparable stability) 4

Important Caveat: Be vigilant for swelling after reduction. Consider bivalving the cast initially and overwrapping after a few days when acute swelling has improved 2

Rehabilitation

1. Early Phase (After Cast Removal)

   • Implement directed home exercise program 1
   • Wrist motion exercises 3 times daily 2
   • If fracture line remains visible on radiographs, use removable wrist splint for additional 2-4 weeks 2

2. Progressive Phase

   • Progressive range of motion exercises 1
   • Full recovery typically expected within 6-8 weeks 1
   • Consider balance training and fall prevention programs in long-term rehabilitation (6-8 weeks and beyond) 1

Pain Management

• NSAIDs for pain and inflammation control 1
• Ice application during first 3-5 days for symptomatic relief 1
• Oral analgesics for residual pain 1

Monitoring and Complications

1. Follow-up Schedule

   • Radiographs at 1 and 2 weeks post-reduction to confirm maintained alignment 2
   • Full return to activity expected at 3 months 2

2. Potential Complications

   • Redisplacement (external fixation has lower risk compared to cast alone: 7/356 vs 51/338) 5
   • Malunion
   • Median nerve compression (assess sensation in thumb, index, and long fingers) 2
   • Reflex sympathetic dystrophy 5

Special Considerations

• Age-Related Factors:

  • Children have higher tolerance for immobilization and faster healing rates 1
  • For patients >60 years with redisplaced fractures, surgical fixation may be necessary to enable functional rehabilitation 6

• Comorbidity Considerations:

  • For diabetic patients: close monitoring of skin to prevent pressure points 1
  • For elderly patients: evaluate osteoporosis risk factors 1
  • For smokers: increased risk of nonunion and inferior outcomes 1

• Cast Care Instructions:

  • Instruct patient not to put anything down the cast to prevent skin breakdown 2
  • Use sharp cast saws and "zip sticks" when removing cast to prevent burns 2