What is the management plan for a patient with a probable intra-articular nondisplaced fracture involving the radial styloid?

Management of Probable Intra-articular Nondisplaced Radial Styloid Fracture

Immobilize the wrist immediately with a sugar-tong splint while allowing full finger motion, begin active finger exercises on day one, apply ice at days 3 and 5, and obtain radiographic follow-up at 3 weeks to confirm healing and rule out secondary displacement. 1

Initial Immobilization Strategy

• Apply a sugar-tong splint that immobilizes the wrist and forearm but leaves the fingers completely free to move 2
• The splint should be padded and comfortably snug without being constrictive 2
• For nondisplaced intra-articular fractures, rigid circumferential casting is not initially required since there is no significant displacement (>3mm) or angulation (>10°) 2, 3

Immediate Rehabilitation Protocol

• Instruct the patient to begin active finger motion exercises immediately upon diagnosis - this is critical to prevent finger stiffness, which is one of the most functionally disabling complications of distal radius fractures 4, 1
• Finger motion does not adversely affect an adequately stabilized distal radius fracture and does not compromise reduction or healing 4
• Do not immobilize the fingers under any circumstances, as this leads to unnecessary stiffness and poor functional outcomes 2

Adjunctive Symptomatic Treatments

• Apply ice at 3 and 5 days post-injury for symptomatic relief 1
• Consider vitamin C supplementation for prevention of disproportionate pain (moderate strength recommendation from the American Academy of Orthopaedic Surgeons) 4, 1
• Consider low-intensity ultrasound for short-term improvement in pain and radiographic union, though long-term benefits remain unproven 1

Follow-Up Protocol

• Obtain radiographic follow-up at 3 weeks to assess healing and rule out secondary displacement 1, 2
• Obtain additional radiographs at the time of immobilization removal 2, 3
• Monitor for complications including skin irritation and muscle atrophy 3

Special Considerations for Intra-articular Fractures

• Since this is an intra-articular fracture, be vigilant about the adequacy of reduction - even acceptably reduced intra-articular distal radial fractures may benefit from operative treatment if there is any concern about articular congruity 5
• If an associated ulnar styloid fracture is present, it typically does not require separate fixation, as studies show no significant difference in outcomes between treatment and non-treatment when the radius fracture is properly managed 4, 1

Critical Pitfalls to Avoid

• Do not overlook rotated osteochondral fragments on imaging - these require surgical intervention and will lead to early osteoarthritis if missed 6
• Avoid prolonged immobilization beyond what is necessary, as this increases risk of stiffness without improving outcomes 4, 3
• Do not routinely begin early wrist motion following stable fracture fixation - the American Academy of Orthopaedic Surgeons suggests patients do not need early wrist motion routinely 4
• Assess for associated distal radioulnar joint (DRUJ) dislocation, which can be difficult to identify but requires different management 4

When to Consider Surgical Referral

• If radiographic follow-up at 3 weeks shows secondary displacement (>3mm displacement or >10° angulation), refer for surgical evaluation 3
• If there is evidence of a rotated palmar medial fragment or significant articular incongruity, immediate orthopedic consultation is warranted 6
• Recent evidence suggests that even acceptably reduced intra-articular distal radial fractures have better functional outcomes at 12 months with operative treatment compared to nonoperative management 5