What are the latest management strategies for distal radius fractures?

Distal Radius Fractures: Comprehensive Management for Orthopedic Surgeons

Surgical Indications: Age-Based Algorithm

Non-Geriatric Patients (<65 years)

Operate on non-geriatric patients when post-reduction imaging shows radial shortening >3mm, dorsal tilt >10 degrees, or intra-articular displacement/step-off >2mm, as this leads to superior radiographic and patient-reported outcomes. 1

• These thresholds represent the evidence-based cutoffs where operative intervention demonstrates clear benefit over conservative management 1
• The moderate strength recommendation means you should generally follow this guideline but remain sensitive to individual patient factors 1

Geriatric Patients (≥65 years)

Do not routinely operate on geriatric patients, as operative treatment fails to improve long-term patient-reported outcomes compared to non-operative management. 1

• This is a strong recommendation that should be followed unless compelling rationale exists for an alternative approach 1
• This represents one of the most significant paradigm shifts in recent distal radius fracture management, challenging traditional surgical indications in elderly patients 1

Surgical Technique Selection

No single fixation technique demonstrates superiority for complete articular or unstable distal radius fractures, though volar locking plates provide faster functional recovery at 3 months. 1

• Volar locking plates, percutaneous K-wires, external fixation, and dorsal plating all achieve equivalent long-term radiographic and functional outcomes 1
• The early functional advantage of volar plating (at 3 months) may justify its use in patients requiring rapid return to work or activities 1
• External fixation systems like the CPX allow wrist rehabilitation as early as 4-16 days post-operatively while maintaining reduction 2

Fixation Position Considerations

• Immobilize in neutral to extended wrist position rather than traditional flexion/ulnar deviation to prevent finger stiffness by relaxing extensor tendons 3
• This approach maintains functional finger motion in 95% of patients during treatment and still restores palmar tilt in 55% of cases 3
• Traditional flexed positioning causes significant finger stiffness requiring prolonged rehabilitation 3

Non-Operative Management

Immobilization Protocol

• Apply sugar-tong splint initially, followed by short-arm cast for minimum 3 weeks 4
• Removable splints are appropriate for minimally displaced fractures 5
• Obtain radiographs at 3 weeks and at immobilization removal to confirm healing 5, 6

Critical Pitfall to Avoid

Never remove immobilization prematurely without radiographic confirmation of healing - immobilization complications (14.7% incidence of skin irritation/muscle atrophy) are minor compared to risks of inadequate healing 5, 6

Immediate Post-Diagnosis Management

Initiate active finger motion exercises immediately following diagnosis, regardless of treatment method chosen. 1, 5

• Finger stiffness is the most functionally disabling complication of distal radius fractures 1
• Active finger motion does not adversely affect adequately stabilized fractures 5
• Early wrist motion is not routinely necessary following stable fixation 5
• Home exercise programs are equivalent to supervised therapy for uncomplicated fractures 1

Associated Injuries Assessment

DRUJ Evaluation

Obtain true lateral radiograph of the carpus post-reduction to assess DRUJ alignment in all patients. 1

• DRUJ instability is difficult to identify with standard views and requires specific lateral imaging 1
• Evidence is inconclusive regarding timing of DRUJ surgical treatment, but identification is critical 1
• Undiagnosed DRUJ instability leads to significantly poorer functional outcomes 1

Median Nerve Injury

• Median nerve compression is the most common complication of distal radius fractures 7
• Persistent nerve dysfunction after reduction may require decompression, though evidence for timing is inconclusive 5

Pain Management

Implement opioid-sparing and multimodal pain strategies for all patients undergoing distal radius fracture treatment. 1

• Consider vitamin C supplementation for prevention of complex regional pain syndrome (moderate recommendation) 5
• Ultrasound and/or ice are adjuvant options, though evidence is weak 5
• Apply ice at 3 and 5 days post-injury for symptomatic relief 8

Pediatric-Specific Considerations

Buckle (Torus) Fractures

• Treat with removable splints for 3-4 weeks 5, 6
• These incomplete compression fractures without cortical disruption require only immobilization 4

Completely Displaced Pediatric Fractures

Reduce completely displaced pediatric distal radius fractures under general anesthesia and fix with percutaneous K-wires, even when satisfactory closed reduction is achieved. 9

• Complete initial displacement is the most important factor leading to redisplacement (25% overall redisplacement rate) 9
• Reduction under deep sedation or local block significantly increases redisplacement risk 9
• Presence of ipsilateral distal ulnar fracture further increases redisplacement risk 9

Follow-Up Protocol

Reevaluate all patients with unremitting pain during follow-up visits. 1

• This consensus recommendation addresses the need for vigilance regarding complications 1
• Unremitting pain may indicate complex regional pain syndrome, malunion, or other complications requiring intervention 1

Complications and Their Prevention

Most Common Complications (in order of frequency):

1. Median nerve compression 7
2. Tendon rupture 7
3. Post-traumatic arthrosis 7
4. Malunion 7
5. Complex regional pain syndrome (preventable with vitamin C) 5

Finger Stiffness Prevention

• Finger stiffness results from pain, swelling, cast obstruction, and patient apprehension 1
• Once established, finger stiffness requires multiple therapy visits and possibly additional surgery 1
• Prevention through immediate active motion is far superior to treatment after development 1

Fragility Fracture Screening

• Evidence is inconclusive for using distal radius fractures to predict future fragility fractures 1
• Diagnostic meta-analysis shows low sensitivity but high specificity for predicting future hip fractures 1
• Consider bone health evaluation in appropriate patients, though formal screening recommendations are not established 1