What is the diagnosis and treatment for a linear lucency traversing the distal radius with mild overlying soft tissue swelling?

Distal Radius Fracture: Diagnosis and Treatment

Diagnosis

A linear lucency traversing the distal radius with mild overlying soft tissue swelling represents a distal radius fracture. 1

Imaging Confirmation

• Obtain a 3-view radiographic examination (posteroanterior, lateral, and 45° semipronated oblique) as this is the standard initial imaging for distal radius fractures and provides sufficient diagnostic information in most cases 1
• A fourth semisupinated oblique view increases diagnostic yield for distal radius fractures if the diagnosis remains uncertain 1
• If initial radiographs show a subtle linear lucency but clinical suspicion remains high, place the patient in a short arm cast and repeat radiographs at 10-14 days to confirm the fracture as it becomes more visible 1, 2

Advanced Imaging Considerations

• CT without IV contrast is the next step if radiographs are equivocal and you need to exclude or confirm the fracture, particularly to assess for intra-articular extension 1
• MRI without IV contrast can detect occult distal radius fractures but adds little value for determining immediate surgical need 1
• Three-dimensional CT reconstructions are particularly helpful for preoperative planning if complex articular injury is suspected 1

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Treatment Algorithm

Initial Management

All distal radius fractures require assessment of displacement, angulation, articular involvement, and associated soft tissue injuries to guide treatment decisions. 1, 2

Non-Displaced or Minimally Displaced Fractures

• Apply a sugar-tong splint initially, followed by conversion to a short-arm cast for a minimum of 3 weeks 2
• Use rigid immobilization (cast) rather than removable splints for displaced fractures to maintain reduction 1
• Removable splints are only appropriate for truly minimally displaced fractures 1
• Obtain radiographs at regular intervals for 3 weeks and at cessation of immobilization to monitor for loss of reduction 1

Indications for Surgical Treatment

Operative fixation is indicated when:

• Coronally oriented fracture line is present 1
• Die-punch depression exists 1
• More than three articular fracture fragments are present 1
• Displacement results in loss of radial length, inclination, or tilt 1
• Residual articular surface step-off >2 mm after reduction (to avoid long-term osteoarthritis) 1

Surgical Considerations

• Arthroscopic assistance during surgery is NOT recommended as moderate evidence shows no improvement in functional outcomes at 48 months compared to fluoroscopic guidance alone 1
• Surgical treatment of associated ligament injuries (scapholunate, lunotriquetral, or TFCC tears) at the time of radius fixation is an option, though evidence is limited 1
• Obtain a post-reduction true lateral radiograph of the carpus to assess distal radioulnar joint (DRUJ) alignment in all cases 1

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Post-Treatment Management

Rehabilitation

• A home exercise program is equally effective as supervised therapy for uncomplicated distal radius fractures 1
• Begin active range of motion exercises for uninvolved joints immediately to prevent stiffness 3, 4
• Finger motion does not adversely affect adequately stabilized fractures and significantly reduces the risk of debilitating stiffness 3, 4

Follow-Up Monitoring

• All patients with unremitting pain during follow-up must be reevaluated as this may indicate complications such as median nerve injury, compartment syndrome, complex regional pain syndrome, or loss of reduction 1, 2, 5
• Median nerve injury is a common complication that should be assessed clinically 2

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Critical Pitfalls to Avoid

• Do not rely on 2-view radiographs alone as they are inadequate for detecting distal radius fractures 1
• Do not delay diagnosis by assuming subtle linear lucencies are artifacts—treat as fracture and reimage at 10-14 days if uncertain 1, 2
• Do not use removable splints for displaced fractures as rigid immobilization is required to maintain reduction 1
• Do not immobilize uninvolved fingers—early motion prevents stiffness, which is more functionally disabling than the fracture itself 3, 4
• Do not ignore persistent pain—it may indicate compartment syndrome, nerve injury, or other serious complications requiring immediate intervention 1, 5, 6