What is the appropriate management for a patient with a minimally displaced, non-comminuted articular fracture of the distal radius, without significant comorbidities or osteoporosis?

Management of Minimally Displaced Articular Distal Radius Fractures

A minimally displaced articular fracture of the distal radius can be managed with removable splint immobilization, but only if the articular step-off is <2 mm and there is no significant displacement, as operative fixation is necessary to prevent long-term osteoarthritis when these thresholds are exceeded. 1

Critical Decision Points for Conservative vs. Operative Management

The key determinant is whether the fracture meets strict radiographic criteria for stability:

Indications for Operative Fixation (NOT splint-only)

• Articular step-off ≥2 mm - This threshold is critical because residual articular surface incongruity beyond this point leads to post-traumatic osteoarthritis 1
• Radial shortening >3 mm 2
• Dorsal tilt >10° 2
• Intra-articular displacement present 2
• Coronally oriented fracture line 1
• Die-punch depression 1
• More than three articular fracture fragments 1

Criteria for Splint-Only Management

Only when ALL of the following are met:

• Articular step-off <2 mm 1
• Radial shortening ≤3 mm 2
• Dorsal tilt ≤10° 2
• Minimal to no displacement 2, 3
• No comminution or <3 articular fragments 1

Conservative Treatment Protocol

Immobilization Approach

• Removable splints are appropriate for minimally displaced distal radius fractures that meet the above criteria 2
• Alternative: Sugar-tong splint initially, followed by short-arm cast for minimum 3 weeks 3
• Duration: Typically 3-6 weeks, though evidence supports as little as 1 week for truly non-displaced fractures 4

Active Mobilization Strategy

• Immediate active finger motion exercises should be performed following diagnosis to prevent stiffness 2
• Finger motion does not adversely affect adequately stabilized distal radius fractures 2
• Early wrist motion is NOT routinely necessary following stable fracture fixation 2

Radiographic Follow-up

• Follow-up imaging at approximately 3 weeks and at time of immobilization removal to confirm adequate healing 2
• Monitor for loss of reduction that would necessitate surgical intervention 2

Critical Pitfalls to Avoid

Underestimating Articular Involvement

The most common error is failing to recognize that even "minimal" articular involvement requires precise measurement of step-off. The 2 mm threshold is absolute - exceeding this significantly increases risk of post-traumatic arthritis 1, 5. Standard 2-view radiographs miss fracture details; obtain 3-view wrist series (PA, lateral, 45° semipronated oblique) at minimum 1.

Inadequate Initial Assessment

• Consider CT without IV contrast when initial radiographs are equivocal, as distal radius fractures may be radiographically occult 1
• Assess for median nerve injury, which commonly complicates distal radius fractures 3

Immobilization Complications

• Monitor for skin irritation or muscle atrophy, which occur in approximately 14.7% of immobilization cases 2
• Removable splints allow adjustment as swelling reduces and permit washing 6

Adjunctive Measures

• Vitamin C supplementation for prevention of disproportionate pain (moderate recommendation strength) 2
• Ultrasound and/or ice as adjuvant treatment options (weak evidence) 2

When Conservative Management Fails

If radiographic follow-up demonstrates loss of reduction with any parameter exceeding the thresholds above, immediate surgical referral is indicated to restore articular congruity and prevent long-term disability 1, 2. Post-traumatic arthritis following distal radius fracture is among the most difficult conditions to salvage and yields poor results 5, making prevention through appropriate initial treatment paramount.