Management of Distal Radial Fractures
Initial Assessment and Treatment Algorithm
The management of distal radial fractures depends critically on displacement: non-displaced or minimally displaced fractures should be treated with removable splints or short-arm casts for 3 weeks, while fractures with >3mm displacement, >10° dorsal tilt, or intra-articular involvement require surgical fixation with volar locked plating. 1
Step 1: Radiographic Assessment
Obtain standard radiographs and measure the following parameters to determine treatment pathway 1:
- Displacement: >3mm indicates surgical management 1
- Dorsal tilt: >10° indicates surgical management 1
- Intra-articular involvement: Any significant step-off requires surgical consideration 1
- Radial shortening: >3mm post-reduction indicates surgical fixation 1
For comminuted intra-articular fractures, CT scanning may improve diagnostic accuracy 2
Non-Displaced or Minimally Displaced Fractures
Immobilization Strategy
Use removable splints as the preferred option for minimally displaced fractures 1. This approach is specifically recommended by the American Academy of Orthopaedic Surgeons and offers advantages over rigid casting 1.
Immobilize for 3 weeks only 1, 3. Research demonstrates that 3 weeks of immobilization produces significantly better patient-reported outcomes (PRWE scores: 5.0 vs 8.8 points, p=0.045; QuickDASH scores: 0.0 vs 12.5, p=0.026) compared to 5 weeks, with no increase in secondary displacement 3.
Immediate Mobilization Protocol
Begin active finger motion exercises immediately after diagnosis 1. The American Academy of Orthopaedic Surgeons emphasizes that finger motion does not adversely affect adequately stabilized distal radius fractures and prevents stiffness, which is one of the most functionally disabling complications 1.
Early wrist motion is not routinely necessary following stable fracture fixation 1.
Follow-up Schedule
Obtain radiographic follow-up at 1:
- 3 weeks: Confirm adequate healing
- At immobilization removal: Final confirmation before discontinuing treatment
Adjunctive Treatments
Consider the following evidence-based adjuncts 1:
- Vitamin C supplementation: Recommended by the American Academy of Orthopaedic Surgeons for prevention of disproportionate pain (moderate recommendation strength)
- Ice application: Option for symptomatic relief, though evidence is weak
- Ultrasound: Option for adjuvant treatment, though evidence is weak
Displaced or Unstable Fractures
Surgical Indications
Proceed directly to surgical fixation when post-reduction imaging shows 1:
- Radial shortening >3mm
- Dorsal tilt >10°
- Intra-articular displacement
- Persistent instability after closed reduction
Surgical Technique
Volar locked plating is the primary surgical treatment recommended by the American Academy of Orthopaedic Surgeons for comminuted intra-articular fractures 2. This approach provides 2:
- Earlier functional return
- Better range of movement
- Less pain and disability
- Earlier wrist mobilization compared to conservative management
Arthroscopic-assisted reduction is an option for improved diagnostic accuracy and allows evaluation and treatment of associated ligament injuries 2.
For severely comminuted fractures with bone voids, bone grafting may be necessary, though evidence regarding outcomes is inconclusive 2.
Post-Surgical Management
- Active finger motion exercises: Begin immediately after surgery to prevent stiffness 2
- Radiographic follow-up: At 3 weeks and at immobilization removal 2
- Early wrist motion: Not routinely necessary following stable fixation 2
Special Considerations and Pitfalls
Buckle (Torus) Fractures in Children
These incomplete compression fractures without cortical disruption can be managed with removable splints for 3 weeks 1, 4.
Median Nerve Injury
Be aware that distal radius fractures may be complicated by median nerve injury 4. If persistent nerve dysfunction occurs after reduction, nerve decompression may be required, though evidence is inconclusive 1.
Monitoring for Complications
Immobilization-related complications occur in approximately 14.7% of cases 1, including:
- Skin irritation
- Muscle atrophy
Monitor patients closely during follow-up visits 1.
When Conservative Management Fails
If rigid immobilization (casting) is chosen over removable splints, it should be reserved for displaced fractures requiring more stability 1. However, the evidence supports that most non-displaced fractures do better with shorter immobilization periods and removable splints 1, 3.