From the Guidelines
Emergency department management of comminuted intraarticular distal radius fractures requires prompt evaluation and stabilization, with a strong emphasis on orthopedic consultation for potential surgical fixation, as these fractures often have poor outcomes with conservative management alone. Initial management includes pain control with appropriate analgesia such as intravenous morphine 0.1 mg/kg or fentanyl 1-2 mcg/kg, along with a peripheral nerve block (e.g., hematoma block with 5-10 mL of 1% lidocaine) for additional pain relief during manipulation, as suggested by the American Academy of Orthopaedic Surgeons/American Society for Surgery of the Hand clinical practice guideline summary management of distal radius fractures 1.
Key Considerations
- Obtain orthogonal radiographs (posteroanterior, lateral, and oblique views) to assess fracture pattern, displacement, and articular involvement.
- Apply a temporary splint after closed reduction if possible; this typically involves longitudinal traction, correction of dorsal angulation, and ulnar deviation.
- The splint should be a sugar-tong or volar splint with the wrist in slight flexion and ulnar deviation.
- Elevate the extremity and apply ice to reduce swelling.
Surgical Options
- External fixation
- Percutaneous pinning
- Open reduction internal fixation (ORIF), depending on fracture characteristics and patient factors, as outlined in the treatment of distal radius fractures guideline 1.
- Definitive treatment decisions are based on fracture stability, articular step-off (>2mm typically requires surgical intervention), radial shortening, and angulation.
Follow-up Care
- Patients should be advised to maintain strict elevation of the extremity and follow up with orthopedics within 5-7 days if not admitted for immediate surgical intervention.
- The American Academy of Orthopaedic Surgeons/American Society for Surgery of the Hand clinical practice guideline summary management of distal radius fractures 1 provides a comprehensive evaluation of the available scientific studies, and readers are urged to consult the full guideline for the comprehensive evaluation of the available scientific studies.
Evidence-Based Recommendations
The American Academy of Orthopaedic Surgeons/American Society for Surgery of the Hand clinical practice guideline summary management of distal radius fractures 1 contains a list of evidence-based prognostic and treatment recommendations, which were established using methods of evidence-based medicine that rigorously control for bias, enhance transparency, and promote reproducibility. The recommendations regarding operative treatment are principally based upon literature studying distal radius fracture as an isolated injury, and mitigating circumstances may also be factors in the shared decision-making process. A strong recommendation means that the quality of the supporting evidence is high, and in this case, the evidence supports prompt orthopedic consultation and potential surgical fixation for comminuted intraarticular distal radius fractures 1.
From the Research
Emergency Department Management of Comminuted Intraarticular Distal Radius Fractures
The management of comminuted intraarticular distal radius fractures in the emergency department involves several treatment options, including:
- Closed reduction and use of a mini-external fixator 2
- Surgical treatment with the small AO external fixation device 3
- Open reduction and internal fixation with volar plating 4
- Combined external fixation and open reduction and volar plating 5
Treatment Options
The choice of treatment depends on the severity of the fracture and the individual patient's needs. Some studies have shown that:
- Closed reduction and use of a mini-external fixator can achieve acceptable outcomes with minimal complications 2
- Surgical treatment with the small AO external fixation device can result in excellent and good results in 90% of patients 3
- Open reduction and internal fixation with volar plating can achieve union in all patients with minimal complications 4
- Combined external fixation and open reduction and volar plating can result in excellent and good results in 81% of patients 5
Key Considerations
When managing comminuted intraarticular distal radius fractures, it is essential to consider the following:
- Accurate reduction of the articular surfaces and sustained restoration of anatomic position 6
- Careful preoperative analysis of individual patients and fractures to determine the best treatment option 6
- The use of radiographic criteria, such as the degree of angulation and shortening of the radius, to evaluate treatment outcomes 2