What is the management of a 5-week-old nondisplaced distal radius fracture (distal radius fracture) with decreased range of motion (ROM) and persistent pain?

From the Guidelines

For a 5-week-old nondisplaced distal radius fracture with decreased range of motion and continued pain, I recommend a comprehensive rehabilitation approach, prioritizing physical therapy and a home exercise program, as supported by the most recent and highest quality study 1. This approach is based on the latest evidence from the American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand, which emphasizes the importance of rehabilitation in the management of distal radius fractures 1.

Key Components of Rehabilitation

• Physical therapy 2-3 times weekly for 4-6 weeks, focusing on gentle active and passive range of motion exercises, progressive strengthening, and proprioceptive training
• A home exercise program to be performed 2-3 times daily, supplementing physical therapy and promoting continuous improvement
• Pain management with acetaminophen 650mg every 6 hours as needed or NSAIDs like ibuprofen 400-600mg every 6-8 hours with food, if not contraindicated
• Use of a removable wrist splint for comfort, but removed for exercises and gradually discontinued as symptoms improve

Considerations and Precautions

• A follow-up X-ray to confirm proper healing progression and rule out any complications
• Further evaluation if pain is severe or function doesn't improve within 2-3 weeks of starting therapy, to rule out complex regional pain syndrome, tendon injury, or other complications The evidence from the American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand 1 supports the use of a home exercise program and supervised therapy following the treatment of distal radius fractures, although the evidence is not consistent across all studies 1. However, the most recent and highest quality study 1 provides the strongest guidance for clinical decision-making.

From the Research

Management of Distal Radius Fracture

• The management of a 5-week-old nondisplaced distal radius fracture with decreased range of motion (ROM) and continued pain can be approached through various methods, considering the fracture's severity, desired functional outcome, and patient comorbidities 2.
• Non-operative management, including immobilization with or without reduction, can give good results, especially in older adults 2.
• A study comparing 3 weeks versus 5 weeks of cast immobilization for non- or minimally displaced distal radial fractures found that shortening the period of immobilization can lead to equal patient-reported outcomes with no negative side effects 3.
• The primary outcomes measured in this study included patient-reported outcomes using the Patient-Related Wrist Evaluation (PRWE) and Quick Disability of Arm, Shoulder and Hand (QuickDASH) score after 1-year follow-up 3.
• Secondary outcome measures included PRWE and QuickDASH scores earlier in follow-up, pain (Visual Analog Scale), and complications like secondary displacement 3.
• Another study protocol aimed to evaluate whether the duration of immobilization of non- or minimally displaced distal radial fractures can be safely reduced, comparing 3 weeks of plaster cast immobilization with 5 weeks 4.
• The expectation of this study was that a shorter duration of plaster cast immobilization would be beneficial for patients with distal radius fractures, with a low risk of specific complications and similar outcomes in both treatment options 4.

Treatment Options

• Treatment options for distal radius fractures include conservative management, internal fixation with pins, bridging and non-bridging external fixation, dorsal or volar plating with/without arthroscopy assistance 5.
• Patients should be encouraged to mobilize as soon as it is safe to do so to prevent stiffness, with median nerve compression being the most common complication, followed by tendon rupture, arthrosis, and malunion 2.
• Adequate pain management is essential to decrease postoperative complications, such as chronic pain and disability, while minimizing the risk of prolonged opioid use and dependence 6.
• Strategies to optimize pain management include regional anesthesia, preoperative dosing of medication, multimodal regimens, long-acting selective opioids at the time of surgery, corticosteroids, and non-pharmacologic therapies 6.