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
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 3
- Removable splints are only appropriate for truly minimally displaced fractures 3
- Obtain radiographs at regular intervals for 3 weeks and at cessation of immobilization to monitor for loss of reduction 3
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, 3
- Residual articular surface step-off >2 mm after reduction (to avoid long-term osteoarthritis) 1, 3
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 4
- Surgical treatment of associated ligament injuries (scapholunate, lunotriquetral, or TFCC tears) at the time of radius fixation is an option, though evidence is limited 3
- Obtain a post-reduction true lateral radiograph of the carpus to assess distal radioulnar joint (DRUJ) alignment in all cases 3
Post-Treatment Management
Rehabilitation
- A home exercise program is equally effective as supervised therapy for uncomplicated distal radius fractures 3
- Begin active range of motion exercises for uninvolved joints immediately to prevent stiffness 5, 6
- Finger motion does not adversely affect adequately stabilized fractures and significantly reduces the risk of debilitating stiffness 5, 6
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 3, 2, 7
- Median nerve injury is a common complication that should be assessed clinically 2
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 3
- Do not immobilize uninvolved fingers—early motion prevents stiffness, which is more functionally disabling than the fracture itself 5, 6
- Do not ignore persistent pain—it may indicate compartment syndrome, nerve injury, or other serious complications requiring immediate intervention 3, 7, 8