What is the preferred method of immobilization, cast or splint, for a distal radius fracture?

Cast vs Splint for Distal Radius Fractures

For displaced distal radius fractures requiring immobilization, use rigid casting rather than removable splints; however, for minimally displaced or nondisplaced fractures, removable splints are an acceptable and often preferred alternative. 1

Treatment Algorithm Based on Fracture Displacement

Displaced Fractures Requiring Nonsurgical Management

• Rigid immobilization (casting) is preferred over removable splints for displaced distal radius fractures that will be managed conservatively 1
• This recommendation carries moderate strength based on AAOS guidelines 1
• The rationale is maintaining adequate reduction and preventing loss of alignment during the critical healing period 1

Minimally Displaced or Nondisplaced Fractures

• Removable splints are an appropriate treatment option for minimally displaced distal radius fractures 1, 2
• Recent high-quality evidence demonstrates that 1 week of cast immobilization followed by mobilization produces equivalent functional outcomes (PRWE scores), pain levels, and patient satisfaction compared to 3-5 weeks of casting 3
• No significant difference in secondary displacement rates (1.0% vs 1.5%) or need for surgery between short and long immobilization periods 3
• Even 3 weeks of immobilization shows better patient-reported outcomes (PRWE 5.0 vs 8.8 points, p=0.045) compared to 5 weeks 4

Surgical Indications (When Immobilization Alone is Inadequate)

Proceed to surgical fixation rather than casting alone when post-reduction imaging shows:

• Radial shortening >3 mm 1, 2
• Dorsal tilt >10° 1, 2
• Intra-articular displacement 1, 2

Duration of Immobilization

• For stable, minimally displaced fractures: 1 week of immobilization is sufficient 3, 5
• For fractures requiring maintained reduction: 3 weeks appears adequate rather than traditional 4-6 weeks 4
• Obtain radiographic follow-up at approximately 3 weeks and at immobilization removal 2

Important Clinical Considerations

Active Motion Exercises

• Initiate active finger motion exercises immediately following diagnosis to prevent stiffness, which is one of the most functionally disabling complications 2
• Finger motion does not adversely affect adequately stabilized distal radius fractures 2
• Early wrist motion is not routinely necessary following stable fracture fixation 2

Elbow Immobilization

• Evidence is insufficient to recommend for or against including the elbow in cast immobilization 1
• One trial showed no difference between above-elbow and below-elbow splinting for maintenance of reduction 1

Common Pitfalls to Avoid

• Do not over-immobilize stable fractures: Prolonged immobilization beyond 3 weeks provides no additional benefit and may worsen functional outcomes 4, 3
• Monitor for immobilization-related complications (skin irritation, muscle atrophy) which occur in approximately 14.7% of cases 2
• Ensure adequate initial assessment: Obtain proper radiographic views to accurately classify displacement and determine appropriate treatment pathway 1

Special Population: Patients >55 Years

• Evidence does not demonstrate differences between casting and surgical fixation in elderly patients 1
• Aged osteoporotic patients tolerate residual deformities better, with clinical results having relatively low correlation with final anatomic alignment 6