What is the management of an impacted fracture of the distal radius?

Management of Impacted Fractures of the Distal Radius

For impacted distal radius fractures, volar locked plating is the primary treatment option, providing earlier functional return and better outcomes compared to conservative management or external fixation, particularly for comminuted intraarticular fractures. 1

Initial Assessment

Determine fracture characteristics to guide treatment:

• Assess degree of displacement: fractures with >3mm displacement or >10° dorsal tilt are considered significantly displaced 2, 1
• Evaluate articular involvement and joint congruity using plain radiographs 1
• Consider CT scanning to improve diagnostic accuracy for intraarticular impacted fractures 1
• Confirm neurovascular status is intact 3

Treatment Algorithm Based on Fracture Pattern

For Minimally Displaced/Nondisplaced Impacted Fractures

• Removable splints are appropriate for minimally displaced fractures 2
• Rigid immobilization (casting) is preferred if there is any concern for stability 2
• Immobilization duration: typically 3-6 weeks with radiographic follow-up at approximately 3 weeks and at cessation of immobilization 2, 1

For Comminuted Intraarticular Impacted Fractures (Primary Recommendation)

Volar locked plating is the treatment of choice 1:

• Provides earlier wrist mobilization, better range of movement, less pain and disability, and early return of function 1
• Leads to earlier recovery of function in the short term (3 months) compared to other fixation methods 4
• No difference exists in long-term outcomes between various fixation techniques for complete articular or unstable distal radius fractures, but volar locked plating offers superior early functional recovery 4

Alternative Surgical Options

• External fixation alone is not recommended for depressed lunate fossa or four-part fractures based on insufficient evidence 4
• External fixation may result in poorer outcomes with prolonged use 4
• Arthroscopic-assisted reduction is an option for improved diagnostic accuracy and allows evaluation/treatment of associated ligament injuries 1

Adjunctive Treatments

Consider the following supplementary interventions:

• Bone grafting may be necessary for severely comminuted fractures with bone voids, though evidence is inconclusive 1
• Vitamin C supplementation is suggested for prevention of disproportionate pain (moderate strength recommendation) 4
• Ultrasound and/or ice are options for adjuvant treatment 4
• Do not routinely fix associated ulnar styloid fractures - insufficient evidence supports routine fixation 4

Postoperative/Immobilization Management

Implement early mobilization protocols:

• Active finger motion exercises should be performed immediately following diagnosis or surgery to prevent stiffness, which is one of the most functionally disabling adverse effects 2, 1
• Finger motion does not adversely affect adequately stabilized distal radius fractures 2
• Early wrist motion is not routinely necessary following stable fracture fixation 2, 1
• Early mobilization after surgical fixation yields better functional outcomes at 6 weeks without increased risk of secondary dislocation 5

Radiographic Follow-up

Frequency of imaging can be reduced without compromising outcomes:

• No difference exists in outcomes based on frequency of radiographic evaluation 4
• Routine radiographs at 1,2,6, and 12 weeks showed no benefit over reduced imaging protocols (only initial images with subsequent imaging only if clinically indicated) 4
• However, obtaining radiographs after 2 weeks may have value in select patients 4

Critical Pitfalls to Avoid

• Avoid overdistraction when using external fixation - prolonged external fixation is associated with poorer outcomes 4
• Do not rely on conservative management for comminuted intraarticular fractures - risk of joint incongruity and subsequent arthritis 1
• Monitor for loss of reduction - articular step-offs exceeding 2mm result in poor outcomes 6, 7
• Prevent joint stiffness through early finger mobilization - this is the most functionally disabling complication 2, 1