What is the recommended management for a minimally displaced intra-comminuted intra-articular fracture of the distal radius that extends to Lister's tubercle with no extensor pollicis longus tendon involvement?

Management of Minimally Displaced Intra-Comminuted Intra-Articular Distal Radius Fracture with Lister's Tubercle Involvement

Conservative management with thumb spica splint immobilization is recommended as the first-line treatment for minimally displaced intra-comminuted intra-articular fractures of the distal radius extending to Lister's tubercle without extensor pollicis longus tendon involvement.

Initial Assessment and Imaging

• Standard radiographs should be the first imaging modality to assess fracture characteristics
• If radiographs are equivocal but clinical suspicion remains high:
  • CT without contrast is recommended to clarify fracture morphology and distinguish fracture patterns 1
  • MRI without contrast can be useful to evaluate associated soft tissue injuries 1

Treatment Algorithm

Conservative Management (Recommended for Minimally Displaced Fractures)

1. Immobilize the thumb in a thumb spica splint to maintain proper alignment and promote healing 1

   • Position the wrist in slight flexion and forearm supination to counteract volar displacement of the distal fragment
   • This is particularly important for fractures involving Lister's tubercle to protect the extensor pollicis longus tendon

2. Pain management:

   • NSAIDs for pain and inflammation control 1
   • Consider vitamin C supplementation to help prevent disproportionate pain 1

3. Follow-up imaging:

   • Standard radiographs to assess for fracture healing and alignment 1
   • If symptoms persist despite normal radiographs, consider advanced imaging (CT/MRI) 1

Surgical Considerations

Surgical intervention should be considered if:

• Articular step-off exceeds 2mm after attempted closed reduction 2
• Fracture becomes unstable during follow-up
• Significant loss of radial length, inclination, or volar tilt occurs

Surgical options include:

1. External fixation - shown to provide good to excellent results in 80% of cases for comminuted intra-articular fractures 3
2. Open reduction and internal fixation - appropriate for restoring articular congruity 4
3. Percutaneous pinning with supplemental fixation 5

Rehabilitation Protocol

1. Limit immobilization duration to prevent complications 1
2. Early mobilization after stable fixation (whether conservative or surgical) 1
3. Implement directed home exercise program including active motion exercises to:
   • Prevent stiffness
   • Promote full recovery 1
4. Regular movement through complete range of motion is crucial for optimal outcomes 1

Monitoring and Complications

• Monitor for:

  • Joint stiffness
  • Chronic pain
  • Post-traumatic arthritis
  • Extensor lag 1
  • Extensor pollicis longus tendon rupture (particularly important with Lister's tubercle involvement) 5

• Delayed treatment can lead to poor outcomes; persistent symptoms warrant prompt advanced imaging rather than prolonged observation 1

Special Considerations

• For diabetic patients: Close monitoring of skin to prevent pressure points and breakdown 1
• For elderly patients: Evaluate for osteoporosis risk factors and consider calcium and vitamin D supplementation 1
• Smoking increases nonunion rates and leads to inferior clinical outcomes 1

The evidence suggests that minimally displaced intra-articular fractures can be successfully managed conservatively with careful immobilization and monitoring, while maintaining the option to convert to surgical management if reduction is lost or symptoms persist.