What is the initial treatment for distal radial fractures?

Initial Treatment of Distal Radial Fractures

The initial treatment of distal radial fractures depends critically on fracture displacement and stability: non-displaced or minimally displaced fractures should be treated with removable splinting for 3-4 weeks, while significantly displaced fractures (>3mm displacement or >10° dorsal tilt) or comminuted intraarticular fractures require surgical management with volar locked plating. 1, 2

Treatment Algorithm Based on Fracture Pattern

Non-Displaced or Minimally Displaced Fractures

• Removable splints are the appropriate initial treatment option for minimally displaced distal radius fractures, as recommended by the American Academy of Orthopaedic Surgeons 1
• The typical immobilization period is 3-4 weeks 3
• Active finger motion exercises must be performed immediately following diagnosis to prevent stiffness, which is one of the most functionally disabling complications of distal radius fractures 1, 3
• Finger motion does not adversely affect adequately stabilized distal radius fractures in terms of reduction or healing 1

Significantly Displaced Fractures

• When displacement exceeds 3mm or dorsal tilt exceeds 10°, or when intra-articular involvement is present, surgical management is indicated instead of conservative treatment 1, 3
• For displaced fractures, rigid immobilization (casting) is preferred over removable splints if non-operative management is chosen 1

Comminuted Intraarticular Fractures

• Volar locked plating is the primary treatment option for comminuted intraarticular fractures, providing earlier functional return and better functional outcomes compared to conservative management 2
• This approach leads to earlier wrist mobilization, better range of movement, less pain and disability, and early return of function 2
• Conservative management is not typically recommended for comminuted intraarticular fractures due to risk of joint incongruity and subsequent arthritis 2

Post-Treatment Immobilization Duration

For Surgical Cases (Volar Locked Plating)

• Immobilization for 1-3 weeks produces superior short-term outcomes compared to 6 weeks of immobilization, with better function, range of motion, and pain scores at 6 weeks post-surgery 4
• The 3-week immobilization group demonstrated significantly better outcomes than the 6-week group across multiple measures including pain, wrist flexion, ulnar deviation, and forearm pronation 4
• No significant differences in adverse events are associated with shorter immobilization periods 4
• Early wrist motion is not routinely necessary following stable fracture fixation 1, 2

For Non-Operative Cases

• Radiographic follow-up is recommended at approximately 3 weeks and at the time of immobilization removal to confirm adequate healing 1, 3

Critical Management Principles

Immediate Post-Treatment Care

• Active finger motion exercises are crucial from day one to prevent stiffness, which can be very difficult to treat after fracture healing 3, 2
• Finger exercises should be performed even during the immobilization period for adequately stabilized fractures 1

Monitoring for Complications

• Monitor for potential complications such as skin irritation or muscle atrophy, which occur in approximately 14.7% of immobilization cases 1, 3
• Joint stiffness is one of the most functionally disabling adverse effects and must be actively prevented 2

Adjunctive Considerations

• CT scanning is an option to improve diagnostic accuracy for intraarticular fractures 2
• Arthroscopic-assisted reduction is an option for improved diagnostic accuracy and treatment of intraarticular fractures, allowing for evaluation and treatment of associated ligament injuries 2
• Consider adjuvant treatment with vitamin C for the prevention of disproportionate pain 3

Common Pitfalls to Avoid

• Do not immobilize for 6 weeks after surgical fixation - this leads to worse short-term functional outcomes without any long-term benefit 4
• Do not delay finger motion exercises - immediate active finger motion is essential and does not compromise fracture healing 1, 3
• Do not treat significantly displaced or comminuted intraarticular fractures conservatively - these require surgical intervention to prevent poor outcomes 1, 2