Management of Distal Radius Fractures
For non-geriatric patients (under 65 years) with post-reduction radial shortening >3mm, dorsal tilt >10 degrees, or intraarticular step-off >2mm, operative fixation should be performed, while geriatric patients (≥65 years) should generally be managed non-operatively as surgery does not improve long-term patient-reported outcomes. 1
Initial Assessment and Decision Framework
Determine Patient Age Category
- Non-geriatric patients (<65 years): Operative treatment leads to improved radiographic and patient-reported outcomes when specific displacement criteria are met 1
- Geriatric patients (≥65 years): Strong evidence demonstrates no improvement in long-term patient-reported outcomes with operative versus non-operative treatment 1
Assess Fracture Stability and Displacement
For all patients, evaluate post-reduction radiographic parameters: 1
- Radial shortening >3mm
- Dorsal tilt >10 degrees
- Intraarticular displacement or step-off >2mm
If any of these criteria are met in non-geriatric patients, proceed with surgical fixation. 1
Non-Operative Management
Indications
- Geriatric patients regardless of displacement (unless compelling rationale exists) 1
- Non-geriatric patients with adequate post-reduction alignment maintained 1
- Stable, minimally displaced fractures 2
Immobilization Protocol
- For comminuted fractures: Use rigid cast immobilization—never use removable splints, as these are only appropriate for stable buckle fractures 2
- For stable fractures: Removable splint is acceptable 3, 4
- Ensure splint never obstructs full finger range of motion 3
Critical Early Mobilization
- Initiate immediate active finger motion exercises to prevent stiffness 3
- Finger motion does not adversely affect adequately stabilized fractures 3
- Avoid prolonged immobilization beyond 3 weeks 4
Follow-Up Imaging
- Obtain radiographs at approximately 3 weeks to confirm maintained alignment 3
- Repeat imaging at time of immobilization removal 3
- Monitor for loss of reduction, as even initially non-displaced fractures can displace during healing 3
Operative Management
Surgical Indications (Non-Geriatric Patients)
Moderate evidence supports operative treatment when post-reduction parameters show: 1
- Radial shortening >3mm
- Dorsal tilt >10 degrees
- Intraarticular displacement >2mm
Fixation Technique Selection
- No significant difference exists between fixation techniques (K-wires, external fixation, volar locking plates) for long-term radiographic or patient-reported outcomes 1
- Volar locking plates provide early recovery advantage at 3 months post-operatively 1
- For severely comminuted patterns, consider spanning fixation or fragment-specific techniques 2
Pain Management Strategy
- Employ opioid-sparing and multimodal pain management strategies 1
Special Considerations
Osteoporosis and Osteopenia
Patients with low bone mineral density face significantly increased postoperative complication risks: 5
- Increased hardware failure (osteopenia P<0.0001, osteoporosis P=0.01) 5
- Increased malunion rates (osteopenia P=0.004, osteoporosis P<0.0001) 5
- Increased surgical site infection (both P<0.0001) 5
- Bone density must be strongly considered in treatment planning 5
Comminuted Fractures in Elderly
- Comminuted fractures are inherently unstable and typically fail to maintain alignment with simple immobilization 2
- If surgery is chosen despite geriatric age, volar locking plates are commonly used 2
- Critical pitfall: Never use removable splints for comminuted fractures 2
Rehabilitation
Post-Treatment Exercise Program
- Inconsistent evidence shows no difference between home exercise programs and supervised therapy 1
- Patient preference should substantially influence this decision 1
- Avoid restricting wrist motion indefinitely after fracture stability is achieved 3
Complications Monitoring
Watch for Common Issues
- Skin irritation and muscle atrophy occur in approximately 14.7% of immobilization cases 3
- Carpal tunnel syndrome, thumb pain, ulnar nerve symptoms 1
- Reevaluate any patient with unremitting pain, as this may indicate complications requiring intervention 4