What is the recommended treatment and management for a distal radial fracture, including splinting and pain management?

Management of Distal Radial Fractures: Splinting and Treatment Approach

Conservative management with immobilization is indicated for distal radius fractures with less than 50% joint involvement, stable joint, and minimal displacement (less than 10 degrees angulation). 1

Initial Assessment and Classification

• Initial evaluation should include standard radiographs (anteroposterior, lateral, and mortise views) to rule out associated fractures or distal radioulnar joint abnormalities 1
• If initial imaging findings are negative but clinical suspicion remains high, CT without contrast is recommended to confirm fracture and assess fragment size 1, 2
• Classification of fracture stability is crucial:
  • Stable fractures: <50% joint involvement, minimal displacement (<10 degrees angulation)
  • Unstable fractures: >50% joint involvement, significant displacement, comminution

Treatment Algorithm

For Stable Fractures (Conservative Management)

1. Initial Immobilization:

   • Apply a sugar-tong splint for initial immobilization 2
   • This maintains reduction while allowing for swelling

2. Definitive Immobilization:

   • Convert to a short-arm cast after swelling subsides (typically 3-7 days)
   • Maintain immobilization for a minimum of 3 weeks 2
   • Regular assessment of wound healing and radiographic union is necessary 1

3. Rehabilitation:

   • Early finger motion is essential to prevent edema and stiffness 1
   • When immobilization is discontinued, aggressive finger and hand motion becomes necessary 1
   • A directed home exercise program can be as effective as supervised therapy for uncomplicated fractures 1

For Unstable Fractures (Surgical Management)

1. Surgical intervention with open reduction and internal fixation (ORIF) is recommended for:

   • Unstable fractures
   • Displaced fractures (especially in patients under 65 years) 1
   • Intra-articular fractures with significant displacement

2. Post-surgical Management Options:

   • Early mobilization has shown better functional outcomes at 6 weeks compared to splinting in older patients (>70 years) 3
   • For patients at high risk of falls, splinting may provide psychological benefit and protection 3

Pain Management

• NSAIDs are recommended for pain and inflammation control 1
• Calcitonin may be considered for pain management in osteoporotic fractures 1
• Vitamin C supplementation may help prevent disproportionate pain 1

Monitoring and Complications

• Regular follow-up imaging is essential to ensure proper healing and alignment 1
• Watch for common complications:
  • Median nerve injury (particularly with distal radius fractures) 2
  • Tendon irritation and rupture, chronic regional pain syndrome, carpal tunnel syndrome 4
  • Joint stiffness, chronic pain, and post-traumatic arthritis 1

Special Considerations

• Diabetic patients require close monitoring of skin to prevent pressure points and breakdown 1
• Smoking cessation is advised as it increases nonunion rates and leads to inferior clinical outcomes 1
• In elderly patients, evaluate for osteoporosis risk factors and consider calcium and vitamin D supplementation 1

Evidence Quality and Limitations

• While surgical methods generally provide better anatomical appearance after fracture healing, evidence is limited regarding better functional and clinical outcomes 5
• Recent evidence suggests early mobilization after surgical fixation leads to better wrist function initially, without increased risk of secondary displacement 3