Does a Metaphyseal Distal Radius Fracture Require Surgery?
Surgery is indicated for distal radius fractures with post-reduction radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement; otherwise, non-operative management with immobilization is appropriate. 1
Decision Algorithm for Surgical vs Non-Operative Management
Initial Assessment and Reduction
- All distal radius fractures should undergo closed reduction and initial splinting, followed by post-reduction radiographs to assess alignment 1
- Obtain a true lateral radiograph of the carpus to assess distal radioulnar joint (DRUJ) alignment 1
Surgical Indications Based on Radiographic Parameters
Proceed with surgical fixation if ANY of the following are present after reduction: 1
- Radial shortening >3 mm
- Dorsal tilt >10°
- Intra-articular displacement
Non-Operative Management for Stable Fractures
Cast or removable splint immobilization is appropriate when: 1, 2
- Post-reduction alignment meets acceptable parameters (radial shortening ≤3 mm, dorsal tilt ≤10°, no intra-articular displacement)
- Fracture is minimally displaced or non-displaced (buckle fractures)
Critical Caveat: Age Considerations
The AAOS guidelines explicitly state they are unable to recommend for or against surgical treatment in patients >55 years due to lack of conclusive evidence showing functional superiority of surgery in this population 1. Research supports this, showing no difference in functional outcomes (DASH scores, pain) at one year between operative and non-operative treatment in elderly patients, despite better radiographic alignment with surgery 3. However, the radiographic thresholds above still apply when making treatment decisions.
Important Pitfall: "Unstable" Fractures
The guidelines acknowledge they cannot recommend for or against casting as definitive treatment of unstable fractures that are initially adequately reduced 1. This creates clinical ambiguity—even if a fracture pattern suggests instability (comminution, metaphyseal involvement), if post-reduction alignment is acceptable, non-operative management remains an option, though close radiographic follow-up is essential 2, 4.
Post-Treatment Management
Immediate Mobilization Protocol
- Start active finger motion exercises immediately at diagnosis to prevent finger stiffness, the most functionally disabling complication 1, 2, 4
- Finger motion does not adversely affect adequately stabilized fractures 1, 2
- The splint must never obstruct full finger range of motion 4
Follow-Up Imaging Schedule
- Radiographic evaluation at approximately 3 weeks to confirm maintained alignment and adequate healing 2, 4
- Repeat imaging at time of immobilization removal 2
- Re-evaluate any patient with unremitting pain during follow-up, as this may indicate complications 1
Wrist Mobilization
- Early wrist motion is not routinely necessary following stable fracture fixation 1
- Home exercise programs are appropriate for patients prescribed therapy after healing 1
Surgical Method Selection
When surgery is indicated, the AAOS cannot recommend for or against any specific surgical method (external fixation, percutaneous pinning, volar plating, dorsal plating) due to insufficient comparative evidence 1. The choice depends on fracture pattern, surgeon experience, and patient factors. Research suggests all methods can be effective when appropriately applied 5, 6, 7.
Complications to Monitor
- Loss of reduction during healing (occurs even in initially well-reduced fractures) 4
- Skin irritation and muscle atrophy (occur in approximately 14.7% of immobilization cases) 2, 4
- DRUJ instability (associated with poorer outcomes if unrecognized) 1
- Persistent nerve dysfunction after reduction may require decompression, though evidence is inconclusive 1