What is the appropriate medical decision making for a radial (bone) fracture?

From the Guidelines

Medical decision making for a radial fracture typically involves a stepwise approach based on fracture characteristics and patient factors, with the goal of restoring anatomical alignment and function while minimizing complications, as outlined in the 2022 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline summary management of distal radius fractures 1. The initial management should include immobilization with a splint or cast, with non-displaced fractures generally treated conservatively using a short arm cast for 4-6 weeks.

• Pain management should consist of acetaminophen (500-1000mg every 6 hours) and/or NSAIDs like ibuprofen (400-600mg every 6-8 hours) for 5-7 days, with elevation and ice application (20 minutes every 2-3 hours) for the first 48-72 hours to reduce swelling.
• Displaced fractures, intra-articular fractures, or those with significant angulation (>10 degrees) typically require surgical intervention, most commonly open reduction and internal fixation (ORIF) with plates and screws, as supported by moderate evidence in patients under 65 years of age 1.
• Post-surgical rehabilitation is essential, beginning with gentle range of motion exercises after cast removal, followed by progressive strengthening exercises.
• Regular follow-up radiographs at 1-2 weeks after initial treatment and then at 6 weeks are necessary to ensure proper healing, although the frequency of radiographic evaluation does not affect outcomes, as demonstrated by a moderate quality study 1.
• Complications to monitor include malunion, nonunion, stiffness, and complex regional pain syndrome. The decision between conservative and surgical management depends on fracture stability, displacement, patient age, functional demands, and comorbidities, with a patient-centered discussion to better understand an individual patient’s values, preferences, and functional demand, as recommended by the AAOS guideline 1.

From the Research

Medical Decision Making for Radial Bone Fractures

• The management of distal radial fractures involves various treatment options, including surgery, cast immobilization, and external fixation 2.
• For dorsally displaced distal radial fractures that can be reduced closed, K-wire fixation and cast immobilization are recommended 2.
• The duration of cast immobilization is a crucial factor in the treatment of non- or minimally displaced distal radial fractures, with studies suggesting that shorter periods of immobilization may lead to better functional outcomes 3, 4.
• A randomized controlled trial found that 3 weeks of cast immobilization resulted in significantly better patient-reported outcomes compared to 5 weeks of immobilization 3.
• Another study found that immobilization periods of 1 and 3 weeks produced superior short-term outcomes compared to 6 weeks of immobilization, with no significant differences in adverse events 4.
• The effectiveness of external fixation and volar locking compression plate in the treatment of distal radius fractures of type C was compared in a prospective randomized study, which found that both methods can obtain satisfactory clinical outcomes, but external fixation has advantages such as less invasion and faster fracture union 5.
• A multicentre randomized controlled trial is currently being conducted to compare 1 week of brace immobilisation with 3 weeks of cast immobilisation in patients with non- or minimally displaced distal radius fractures, aiming to evaluate the non-inferiority of 1 week of brace immobilisation 6.

Treatment Options

• Surgery: K-wire fixation and cast immobilization are recommended for dorsally displaced distal radial fractures that can be reduced closed 2.
• Cast immobilization: The duration of cast immobilization is a crucial factor in the treatment of non- or minimally displaced distal radial fractures, with shorter periods of immobilization potentially leading to better functional outcomes 3, 4.
• External fixation: External fixation has advantages such as less invasion and faster fracture union compared to volar locking compression plate in the treatment of distal radius fractures of type C 5.
• Brace immobilisation: A multicentre randomized controlled trial is currently being conducted to compare 1 week of brace immobilisation with 3 weeks of cast immobilisation in patients with non- or minimally displaced distal radius fractures 6.