What is the recommended management for a distal radial fracture?

Distal Radial Fracture Management

The recommended management for distal radial fractures includes conservative treatment with immobilization for stable fractures with less than 50% joint involvement and minimal displacement (less than 10 degrees angulation), while surgical intervention with open reduction and internal fixation (ORIF) is recommended for unstable fractures. 1

Initial Evaluation and Imaging

• Standard radiographic evaluation should include:

  • Posteroanterior view
  • Lateral view
  • Oblique view 1

• Advanced imaging may be necessary:

  • CT scans for complex fracture patterns and displaced fragments
  • MRI when soft tissue injuries are suspected
  • CT or MR arthrography for detailed assessment of osteochondral lesions 1

Treatment Algorithm

Conservative Management

Conservative treatment is appropriate for:

• Fractures with less than 50% joint involvement
• Stable joint
• Minimal displacement (less than 10 degrees angulation) 1

Implementation:

1. Initial immobilization with a sugar-tong splint 2
2. Conversion to short-arm cast for minimum of three weeks 2
3. Early finger motion exercises to prevent edema and stiffness 1
4. A directed home exercise program can be as effective as supervised therapy for uncomplicated cases 1

Surgical Management

Surgical intervention is indicated for:

• Unstable fractures
• Significant displacement
• Intra-articular involvement 1

Surgical options include:

• Open reduction and internal fixation (ORIF) - recommended for unstable fractures 1
• External fixation - has some supporting evidence 3
• Percutaneous pinning - has some supporting evidence 3

Special Considerations

Age-Related Factors

• Patients under 65 years with displaced fractures particularly benefit from treatment 1
• For elderly patients:
  • Evaluate for osteoporosis risk factors
  • Consider calcium and vitamin D supplementation 1
  • Orthogeriatric co-management improves functional outcomes and reduces mortality 1

Pediatric Considerations

• Buckle (torus) and greenstick fractures are common in children and can often be managed with immobilization alone 2, 4
• For displaced pediatric fractures:
  • Closed reduction and immobilization is typically the method of choice 4
  • Primary Kirschner wire fixation should be considered for cases with repeated reduction maneuvers or residual displacement 4

Rehabilitation Protocol

1. Early finger motion during immobilization period 1
2. Aggressive finger and hand motion when immobilization is discontinued 1
3. Wrist motion exercises three times daily after cast removal 5
4. Removable wrist splint for 2-4 weeks if fracture line remains visible on radiographs 5
5. Full return to activity expected at 3 months 5

Complications and Prevention

• Monitor for potential complications:

  • Joint stiffness
  • Chronic pain
  • Recurrent instability
  • Post-traumatic arthritis
  • Median nerve injury 1, 2

• Preventive measures:

  • Advise smoking cessation as it increases nonunion rates 1
  • Close monitoring of skin in diabetic patients to prevent pressure points 1
  • Regular assessment of wound healing and radiographic union 1
  • Monitor for hardware-related pain in surgical cases 1

Follow-up Protocol

• Radiographic follow-up at 1 and 2 weeks post-treatment to confirm maintained alignment 5
• Regular assessment of fracture healing and functional recovery 1
• Consider secondary fracture prevention strategies for fragility fractures 1

While the Cochrane review from 2003 noted inadequate evidence to confirm that better anatomical appearance resulted in better functional outcomes 3, more recent guidelines from the American Academy of Orthopaedic Surgeons and American College of Radiology provide clearer treatment recommendations based on fracture characteristics 1.