Treatment of Non-Displaced Distal Radial Metadiaphyseal Fracture with Mild Angulation in a 12-Year-Old
A 12-year-old with a non-displaced distal radial metadiaphyseal fracture and mild angulation should be treated with removable splinting for 3 weeks, followed by active finger motion exercises immediately upon diagnosis. 1
Initial Management
Conservative treatment with immobilization is the appropriate first-line approach for this fracture pattern. 1 The American Academy of Orthopaedic Surgeons specifically recommends removable splints as an appropriate option for minimally displaced distal radius fractures. 1
Key Treatment Components:
- Immobilization duration: 3 weeks with a removable splint 1
- Immediate finger exercises: Active finger motion should begin immediately following diagnosis to prevent stiffness, which is one of the most functionally disabling complications 1
- Radiographic follow-up: Obtain radiographs at approximately 3 weeks and at the time of immobilization removal to confirm adequate healing 1
Critical Decision Points: When Surgery Is NOT Needed
For a 12-year-old with a non-displaced fracture and only mild angulation, surgical intervention is not indicated unless specific radiographic thresholds are exceeded. 2, 1
Acceptable Parameters for Conservative Treatment in Adolescents:
At age 12, the following angulation limits are generally acceptable for non-operative management:
- Angulation up to 15 degrees for distal fractures is acceptable 3
- Complete bayonet apposition is acceptable as long as angulation does not exceed 20 degrees and at least 2 years of growth remains 3
- Recent evidence shows that even residual angulation up to 20 degrees rarely requires corrective osteotomy in adolescents 4
Red Flags Requiring Surgical Consideration:
Surgery would be indicated if post-reduction imaging shows: 2, 1
- Radial shortening >3mm
- Dorsal tilt >10 degrees
- Intra-articular displacement or step-off >2mm
Monitoring Strategy
Early Follow-Up (1-2 Weeks):
- Obtain radiographs between 1-2 weeks after initial reduction to detect early angulation or re-displacement 3
- This is particularly important in adolescents, as 71.4% of initially non-operatively managed displaced fractures re-displaced requiring surgery 4
Intermediate Follow-Up (3 Weeks):
- Radiographic confirmation of healing at approximately 3 weeks 1
- Assessment for any complications such as skin irritation or muscle atrophy (occurs in 14.7% of immobilization cases) 1
Final Assessment:
- Radiographs at immobilization removal 1
Rehabilitation Protocol
- Active finger motion exercises should begin immediately upon diagnosis—this does not adversely affect adequately stabilized distal radius fractures 1
- Early wrist motion is not routinely necessary following stable fracture fixation 1
Common Pitfalls to Avoid
Do Not Delay Radiographic Follow-Up:
- Failure to obtain 1-2 week radiographs may miss early re-displacement that could require intervention 3
- In adolescents specifically, metaphyseal distal radius fractures have a higher risk of early re-displacement when not adequately monitored 4
Do Not Immobilize Fingers:
- Finger stiffness is highly disabling and preventable with immediate active motion 1
Do Not Over-Treat:
- Recent evidence shows that both casting and fixation result in similar final angulation in adolescents 4
- Complications (14.3%) only occurred in those who underwent fixation, not in those treated with casting alone 4
- Even with residual angulation up to 20 degrees, long-term issues are rare and corrective osteotomy is rarely needed 4
Rare but Important Consideration
While extremely uncommon, be aware that metaphyseal fractures not involving the physis can rarely lead to growth arrest (reported in isolated case reports). 5 However, this should not alter initial conservative management for a non-displaced fracture with mild angulation, as the risk is exceedingly low and does not justify prophylactic surgical intervention.