From the Guidelines
The management of an undisplaced transverse fracture of the distal radial metaphysis typically involves immobilization with a short arm cast or a removable splint for 4-6 weeks, with a focus on patient-centered discussion to understand individual patient’s values, preferences, and functional demand. The indication for fixation of distal radius fractures has been updated to reflect patients under the age of 65, with moderate support for operative fixation in non-geriatric patients with post-reduction radial shortening >3mm, dorsal tilt >10 degrees, or intra-articular displacement or step-off >2mm 1. However, for undisplaced fractures, immobilization is often sufficient.
Initially, a well-padded short arm cast with the wrist in a neutral or slightly extended position is recommended. After 3 weeks, depending on clinical and radiographic healing, transition to a removable splint may be appropriate to allow for gentle range of motion exercises while still providing protection. Pain management should include acetaminophen (500-1000mg every 6 hours as needed) or NSAIDs like ibuprofen (400-600mg every 6-8 hours with food) for the first 1-2 weeks. Elevation of the arm above heart level and application of ice for 15-20 minutes several times daily during the first 48-72 hours will help reduce swelling.
Follow-up radiographs are not necessary unless clinically indicated, as no difference exists in outcomes based on frequency of radiographic evaluation for patients treated for distal radius fractures 1. After cast removal, physical therapy focusing on wrist and finger range of motion, strengthening exercises, and gradual return to activities is recommended to restore full function. However, the evidence is inconsistent regarding the use of routine supervised hand therapy for improving outcomes, and it is possible that specific subsets of patients may benefit from supervised hand therapy 1.
Key considerations in the management of these fractures include:
- Immobilization for 4-6 weeks
- Pain management with acetaminophen or NSAIDs
- Elevation and ice to reduce swelling
- Follow-up radiographs only as clinically indicated
- Physical therapy after cast removal to restore function
- Patient-centered discussion to inform decision-making, considering individual patient’s values, preferences, and functional demand 1.
From the Research
Healing Process
- The healing process of an undisplaced transverse fracture of the distal radial metaphysis can be influenced by the duration of cast immobilization 2.
- A study found that shortening the period of immobilization to 3 weeks can lead to equal patient-reported outcomes compared to 5 weeks of immobilization 2.
- However, the optimal management of distal radial fractures is still a topic of debate, and different treatment algorithms have been proposed 3.
Treatment Options
- Conservative management with cast immobilization is a common treatment approach for non- or minimally displaced distal radial fractures 2, 4.
- Surgical management, such as volar plate fixation, may be considered for fractures with coronal shift or other complications 4.
- The use of a distraction plate can be an effective technique for treating fractures with extensive metaphyseal and diaphyseal comminution 5.
Risk Factors for Loss of Reduction
- Initial angulation in the coronal plane and post-reduction translation in the coronal plane are independent predictors for loss of reduction in patients with isolated distal radial metaphyseal fractures and intact ulnas 6.
- Patients with greater than 11° of initial angulation in the coronal plane are at higher risk of losing reduction 6.
- Residual translation in the coronal plane after closed reduction can also increase the risk of loss of reduction 6.