What is the management algorithm for distal radius fractures in orthopedic surgery?

Distal Radius Fracture Management Algorithm

Initial Decision: Age-Based Treatment Strategy

For geriatric patients (≥65 years), non-operative treatment should be the default approach regardless of radiographic parameters, as operative treatment does not improve long-term patient-reported outcomes. 1

For non-geriatric patients (<65 years), operative fixation is indicated when post-reduction radiographs show any of the following: radial shortening >3mm, dorsal tilt >10 degrees, or intra-articular displacement/step-off >2mm. 1

Step 1: Patient Age Stratification

Geriatric Patients (≥65 years old)

• Default to non-operative management with closed reduction and immobilization 1
• Strong evidence demonstrates no long-term functional benefit from surgery in this population 1
• Consider operative treatment only with clear, compelling rationale (e.g., polytrauma, bilateral injuries, patient-specific functional demands) 1

Non-Geriatric Patients (<65 years old)

• Proceed to Step 2 for radiographic assessment 1

Step 2: Post-Reduction Radiographic Assessment (Non-Geriatric Patients)

Obtain post-reduction radiographs and measure the following parameters:

Operate if ANY of these criteria are met: 1

• Radial shortening >3mm
• Dorsal tilt >10 degrees
• Intra-articular displacement or step-off >2mm

Non-operative management if ALL parameters are acceptable: 1

• Radial shortening ≤3mm
• Dorsal tilt ≤10 degrees
• Intra-articular displacement ≤2mm

Step 3: Operative Technique Selection (When Surgery Indicated)

Choose any fixation method based on surgeon preference and fracture pattern, as no technique demonstrates superior long-term outcomes. 1

Available options include: 1

• Volar locking plates (provides faster functional recovery at 3 months)
• Percutaneous pinning (suitable for extra-articular and minimally comminuted intra-articular fractures) 2
• External fixation (indicated for severe intra-articular comminution, though dorsomedial fragments may require supplemental pinning) 2
• Fragment-specific fixation

Volar locking plates offer the advantage of earlier return to function within the first 3 months post-operatively, though long-term outcomes are equivalent. 1

Arthroscopic Assistance

• Not routinely necessary, as outcomes are equivalent with or without arthroscopy 1
• May be considered for complex intra-articular fractures requiring precise visualization 2

Step 4: Non-Operative Management Protocol

For patients managed non-operatively:

• Apply sugar-tong splint initially, followed by short-arm cast 3
• Minimum immobilization duration: 3 weeks 3
• Obtain radiographs at 3 weeks to assess maintenance of reduction 3
• Repeat imaging at time of cast removal to confirm healing 3
• Initiate active finger motion exercises immediately to prevent stiffness 3

Step 5: Pain Management Strategy

Implement multimodal, opioid-sparing analgesia for all patients. 1

Recommended modalities include: 1

• Local anesthetics
• NSAIDs
• Acetaminophen
• Ice, elevation, compression
• Cognitive therapies

Step 6: Rehabilitation

Home exercise programs are equivalent to supervised therapy, so patient preference should guide this decision. 1

• Either approach is acceptable 1
• Focus on preventing finger stiffness, which is the most functionally disabling complication 3

Critical Pitfalls to Avoid

• Do not operate on geriatric patients based solely on radiographic parameters – strong evidence shows no benefit 1
• Do not assume all fixation techniques are equal in the short term – volar locking plates provide faster early recovery despite equivalent long-term outcomes 1
• Do not overlook median nerve injury – this is a common complication of distal radius fractures requiring assessment 3
• Do not remove immobilization prematurely – confirm healing radiographically before discontinuing treatment 3
• Do not neglect immediate finger range of motion exercises – stiffness is highly disabling and preventable 3

Special Considerations

These recommendations apply to isolated distal radius fractures; mitigating circumstances (polytrauma, bilateral injuries, ipsilateral upper extremity injuries) may alter the treatment algorithm and require individualized shared decision-making. 1