Surgical Tips and Tricks for Young Surgeons Managing Distal Radius Fractures
Key Surgical Indications: Know When to Operate
For non-geriatric patients (<65 years), operate when post-reduction imaging shows radial shortening >3mm, dorsal tilt >10 degrees, or intraarticular step-off >2mm 1. These thresholds are critical—memorize them, as they predict improved radiographic and patient-reported outcomes with surgical intervention 1.
For geriatric patients (≥65 years), strongly consider non-operative management 1. Strong evidence demonstrates that surgery does not improve long-term patient-reported outcomes in this population, making conservative treatment the preferred approach unless compelling circumstances exist 1.
Fixation Technique Selection: Volar Plating Wins Early
Choose volar locked plating as your primary technique for unstable and complete articular fractures 1, 2. While strong evidence shows no difference in long-term outcomes between fixation methods (volar plates, dorsal plates, external fixation, K-wires), volar locked plating provides superior early functional recovery at 3 months 1. For comminuted intraarticular impacted fractures specifically, volar locked plating offers earlier wrist mobilization, better range of motion, less pain and disability, and faster return to function 2.
Critical Surgical Pitfall: Articular Fragment Escape
Thoroughly assess for volar lunate facet, radial column, and dorsal lunate facet fragments preoperatively—these are the patterns most prone to fixation failure 3. Articular fragment escape with resultant carpal subluxation is an uncommon but devastating complication that occurs when displaced fragments are poorly reduced or inadequately captured by your plate 3.
Prevention strategies:
- Obtain CT imaging for complex intraarticular fractures to improve diagnostic accuracy 2
- Select implants specifically designed to capture problematic fragments 3
- Ensure adequate postoperative immobilization duration based on fracture pattern 3
- Recognize high-risk patterns during preoperative planning 3
Surgical Approach Selection
Master the volar (Henry) approach as your workhorse exposure 4. The distal radius has three cortical sides and two articular surfaces, requiring versatility in surgical approaches 4. Understanding the soft tissue envelope—rich in vascularity and cutaneous innervation—is essential for safe exposure 4.
Approach algorithm:
- Volar approach: Most fractures, especially those amenable to volar plating 4
- Radial approach: Radial column fractures 4
- Dorsal approach: Dorsal rim fragments, dorsal lunate facet fractures 4
- Arthroscopic assistance: NOT routinely recommended—moderate evidence shows no outcome difference compared to fluoroscopic guidance alone 1
Intraoperative Technical Hacks
Avoid overdistraction when using external fixation 2. Prolonged external fixation correlates with poorer outcomes 2.
Do not routinely fix associated ulnar styloid fractures 2. The AAOS recommends against routine fixation due to insufficient evidence of benefit 2.
Verify true lateral radiographs intraoperatively to assess DRUJ involvement and alignment 5. This prevents missing associated DRUJ instability 5.
Immediate Post-Operative Management
Initiate active finger motion exercises immediately following surgery 2, 5. Finger stiffness is one of the most functionally disabling complications and can be difficult to treat after fracture healing, potentially requiring multiple therapy visits or additional surgery 2, 5. Finger motion does not adversely affect adequately stabilized fractures 2.
Early wrist motion is NOT routinely necessary following stable fixation 2. Focus on finger mobilization first 2.
Rehabilitation Protocol
Prescribe a home exercise program rather than supervised therapy 1. Limited evidence suggests no difference in outcomes between home exercises and supervised therapy, making home programs cost-effective and patient-friendly 1.
Pain Management Strategy
Implement opioid-sparing multimodal pain management protocols 1. While evidence specific to distal radius fractures is limited, consensus supports this approach 1.
Consider vitamin C supplementation for prevention of disproportionate pain 2. Moderate strength evidence supports this adjunctive treatment 2.
Ultrasound and/or ice are reasonable adjuvant options 2.
Follow-Up Imaging Protocol
Reduce imaging frequency without compromising outcomes 1, 2. The AAOS suggests that routine radiographs at 1,2,6, and 12 weeks show no benefit over reduced imaging protocols 2. Standard protocol: obtain radiographs at approximately 3 weeks post-operatively and at cessation of immobilization (typically 3-6 weeks total) 2.
Reevaluate any patient with unremitting pain during follow-up to identify potential complications 5.
Immobilization Duration
Plan for 3-6 weeks of immobilization with radiographic follow-up at 3 weeks 2. Adjust based on fracture stability and patient factors 2.
Common Complications to Anticipate
Monitor for loss of reduction, especially in the first 3 weeks 5. This is particularly common in displaced fractures treated without adequate fixation 5.
Prevent joint stiffness through aggressive early finger mobilization 2. This is the most functionally disabling complication and your primary modifiable risk factor 2.
Avoid conservative management for comminuted intraarticular fractures 2. These carry high risk of joint incongruity and subsequent post-traumatic arthritis 2.