What is the recommended treatment for a comminuted impacted intraarticular distal radius fracture?

Treatment of Comminuted Impacted Intraarticular Distal Radius Fracture

Surgical fixation with volar locked plating is the recommended treatment for comminuted impacted intraarticular distal radius fractures, as it provides better functional outcomes compared to conservative management. 1

Assessment and Classification

• Intraarticular fractures with displacement require careful evaluation of the degree of displacement, joint congruity, and stability to determine the optimal treatment approach 2
• CT scanning is an option to improve diagnostic accuracy for these fractures 3
• Fractures are classified as significantly displaced when there is >3mm displacement or >10° dorsal tilt 2

Treatment Algorithm

Surgical Options (Preferred for Comminuted Intraarticular Fractures)

1. Primary Treatment Option: Volar Locked Plating

   • Provides earlier functional return in the short term compared to other fixation methods 1
   • Leads to better functional outcomes compared to conservative management 1
   • Results in early wrist mobilization, better range of movement, less pain and disability, and early return of function 4

2. Alternative Surgical Approaches:

   • Combined internal and external fixation
     • Particularly useful for severely comminuted (AO type-C3) fractures 5
     • Can restore radiographic parameters to nearly normal values and maintain reduction throughout healing 5
   • External fixation with K-wire augmentation
     • Viable alternative but with higher complication rates and slower functional recovery compared to volar plating 4
   • Arthroscopic-assisted reduction
     • Option for improved diagnostic accuracy and treatment of intraarticular fractures 3
     • Allows for evaluation and treatment of associated ligament injuries 3

Adjunctive Treatments

• Bone grafting may be necessary for severely comminuted fractures with bone voids, though evidence is inconclusive regarding outcomes 3
• Arthroscopic evaluation of associated ligament injuries (SLIL injuries, LT, or TFCC tears) at the time of radius fixation is an option 3
• K-wire supplementation may be necessary in addition to primary fixation in some cases 6

Postoperative Management

• Active finger motion exercises should be performed following surgery to prevent stiffness 1
• Radiographic follow-up is recommended at approximately 3 weeks and at the time of immobilization removal 1
• Early wrist motion is not routinely necessary following stable fracture fixation 7

Expected Outcomes

• With proper surgical management, grip strength can be restored to approximately 70-80% of the uninjured side 5, 4
• Range of motion typically reaches 70-75% of the contralateral side after surgery 8
• Total articular incongruity immediately postoperatively has a strong correlation with functional outcome 5

Potential Complications

• Joint stiffness is one of the most functionally disabling adverse effects 1
• Fracture collapse requiring additional procedures 5
• Reflex sympathetic dystrophy 5, 9
• Loss of reduction, particularly in cases without bone grafting 9
• Implant-related complications such as hardware irritation 4

Important Considerations

• The degree of articular step-off, gap between fragments, and radial shortening correction strongly correlates with improved outcomes 8
• The number of fracture fragments correlates most closely with functional outcome 8
• Conservative management is not typically recommended for comminuted intraarticular fractures due to risk of joint incongruity and subsequent arthritis 2