What is the recommended treatment for a pediatric patient with an incomplete fracture of the distal radial metaphysis and slight dorsal angulation?

Treatment of Pediatric Incomplete Distal Radial Metaphyseal Fracture with Slight Dorsal Angulation

For a pediatric patient with an incomplete fracture of the distal radial metaphysis and slight dorsal angulation, immobilization with a cast or removable splint without manipulation is the recommended treatment, as these fractures have excellent remodeling potential and rarely require reduction. 1

Initial Management

• Immobilize without manipulation for incomplete fractures with minimal angulation (≤15 degrees), as these fractures demonstrate excellent remodeling capacity and manipulation is unnecessary 1
• Apply a well-molded cast or removable splint to provide adequate stabilization 2
• Begin active finger motion exercises immediately upon diagnosis to prevent finger stiffness, which is one of the most functionally disabling complications of distal radius fractures 3, 4

Acceptable Angulation Parameters

The evidence supports conservative management based on age-specific angulation thresholds:

• Children under 10 years: Accept up to 20 degrees of angulation, as marked remodeling potential exists 5
• Children over 10 years: Accept up to 15 degrees of angulation 5
• Studies demonstrate that fractures with ≤15 degrees of initial angulation managed without reduction rarely progress beyond 20 degrees, and even those reaching 30-35 degrees remodel to near-perfect alignment within 2 years 1

Follow-Up Protocol

• Obtain radiographic follow-up at 3 weeks to assess healing and rule out secondary displacement 4
• Clinical assessment should confirm normal function and absence of visible deformity by 6 weeks post-injury 1
• All patients typically return to normal activities within 10 weeks 5

Adjunctive Treatments

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

When Manipulation IS Required

Manipulation should only be considered if:

• Substantial displacement (>50% cortical contact loss) or angulation exceeds age-appropriate thresholds 5
• The fracture is complete (bi-cortical) rather than incomplete 1
• However, avoid manipulation if presenting >10 days post-injury due to increased risk of physeal arrest 6

Critical Pitfall to Avoid

Do not manipulate incomplete fractures with slight angulation. A retrospective cohort of 124 minimally angulated pediatric distal radius fractures managed with immobilization alone showed zero patients required subsequent manipulation, and all achieved normal function by 6 weeks with no clinically apparent deformity 1. The remodeling potential in children makes aggressive intervention unnecessary and potentially harmful.

Surgical Fixation Considerations

Percutaneous Kirschner wire fixation is not indicated for incomplete fractures with slight angulation. Wire fixation should be reserved for:

• Unstable fractures with >50% displacement that cannot maintain acceptable reduction in a cast 5
• However, note that wire fixation in pediatric distal radius fractures is associated with restricted wrist motion at skeletal maturity compared to cast treatment alone 7