Management of Acute Displaced Transverse Distal Radius Fracture with Dorsal Displacement
Fracture Characterization
This is a Colles-type fracture pattern requiring urgent treatment decision-making based on patient age and functional demand, with the positive ulnar variance suggesting either pre-existing anatomy or associated distal radioulnar joint (DRUJ) disruption that must be addressed 1, 2.
Treatment Algorithm Based on Patient Age
For Non-Geriatric Patients (<65 years)
Operative fixation is indicated given the significant dorsal displacement described, as moderate evidence supports surgical treatment for post-reduction dorsal tilt >10 degrees, radial shortening >3mm, or intraarticular step-off >2mm in this population, leading to improved radiographic and patient-reported outcomes 1.
Surgical approach options include:
- Volar locking plates (preferred for earlier functional recovery at 3 months) 1
- External fixation with or without Kirschner wires 1
- Percutaneous pinning for less complex patterns 1
Strong evidence demonstrates no significant difference in long-term outcomes between fixation techniques, though volar locking plates provide faster short-term functional recovery 1.
For Geriatric Patients (≥65 years)
Strong evidence indicates that operative treatment does not lead to improved long-term patient-reported outcomes compared to non-operative treatment in patients 65 years and older, despite achieving better radiographic parameters 1.
However, the critical caveat: Age 65 serves as a proxy for functional demand, not an absolute cutoff. A patient-centered discussion understanding individual functional demands, values, and preferences should guide decision-making rather than age alone 1.
Addressing the Positive Ulnar Variance
The positive ulnar variance requires specific attention:
- Assess for DRUJ instability clinically and radiographically, as distal radius fractures with dorsal displacement frequently cause DRUJ disruption 2
- If the ulnar variance is due to concomitant distal ulnar metaphyseal fracture: operative fixation should be considered if there is malalignment or instability after radius fixation 3
- If due to ulnar styloid fracture: surgical treatment is generally not indicated, as ulnar styloid nonunion rarely causes clinical problems and does not affect outcomes when the radius is treated with modern fixation methods 3
- Arthroscopic evaluation is an option to assess for triangular fibrocartilage complex (TFCC) tears or carpal ligament injuries, though this provides only short-term functional benefit at 3 months 1
Non-Operative Management Protocol (If Selected)
If non-operative treatment is chosen:
- Closed reduction under anesthesia followed by rigid immobilization is preferred over removable splints for displaced fractures 1
- Sugar-tong splint initially, transitioning to short-arm cast for minimum 3 weeks 4
- Serial radiographic monitoring: Recent evidence shows no difference in outcomes based on frequency of radiographic evaluation, though obtaining films at 2 weeks may identify loss of reduction requiring intervention 1
- Early finger motion is essential to prevent edema and stiffness during immobilization 1
Critical Pitfalls to Avoid
Median nerve injury: Distal radius fractures with significant displacement may be complicated by median nerve injury—assess and document neurovascular status immediately 4, 5.
Irreducible fractures: High-energy fractures with severe dorsal displacement may have volar structures (flexor tendons, median nerve) displaced dorsally, making closed reduction impossible and requiring urgent operative intervention 5.
Underestimating functional demand in older patients: While strong evidence supports non-operative treatment in geriatric patients, highly active individuals over 65 may benefit from surgery based on functional demand rather than chronologic age 1.
Inadequate DRUJ assessment: Failure to recognize and treat DRUJ instability leads to poor outcomes regardless of radius fixation quality 2.
Postoperative/Post-Reduction Care
Rehabilitation protocol:
- Immediate finger range-of-motion exercises to prevent stiffness 1
- Aggressive hand and finger motion once immobilization discontinued 1
- Home exercise programs are equivalent to supervised therapy for most patients, allowing flexibility in rehabilitation approach 1
- Long-term balance training and fall prevention for fragility fracture patients to prevent subsequent fractures 1
Osteoporosis evaluation: All patients over 50 with fragility fractures require bone density assessment and consideration for pharmacological treatment to prevent future fractures 1.