What is the recommended treatment for a patient with a distal radius fracture and greater than 20% volar angulation?

Treatment of Distal Radius Fracture with >20% Volar Angulation

For patients under 65 years of age with distal radius fractures showing >20% volar angulation (equivalent to >10 degrees volar tilt) after reduction, surgical fixation is recommended based on moderate evidence demonstrating improved radiographic outcomes, though the specific surgical technique can be chosen based on surgeon preference and fracture characteristics. 1

Age-Based Treatment Algorithm

Patients <65 Years Old

• Surgical fixation is indicated when post-reduction parameters show:

  • Dorsal tilt >10 degrees (or volar angulation >10 degrees) 1
  • Radial shortening >3mm 1
  • Intra-articular displacement or step-off >2mm 1

• The 2022 AAOS/ASSH guidelines provide moderate evidence supporting operative fixation in non-geriatric patients meeting these criteria, based on 1 high-quality and 26 moderate-quality studies 1

Patients ≥65 Years Old

• Surgical fixation does NOT lead to improved long-term patient-reported outcomes compared to non-operative treatment, despite achieving better radiographic parameters 1

• This recommendation is supported by strong evidence from 2 high-quality and 11 moderate-quality studies 1

• The age cutoff of 65 serves as a proxy for functional demand; treatment decisions should prioritize individual functional requirements over chronological age 1

Surgical Technique Selection

• No single surgical fixation method demonstrates superior outcomes for complete articular or unstable distal radius fractures, according to strong evidence from the 2022 guidelines 1

• Available surgical options include:

  • Volar locking plate fixation 1
  • External fixation 1
  • Percutaneous pinning 1
  • Open reduction and internal fixation 2

• The choice of technique should be based on fracture pattern, surgeon experience, and patient factors rather than evidence of superiority of one method 1

Critical Considerations for Volar Angulation

Why Volar Angulation Matters

• Volar angulation represents loss of normal dorsal tilt, which can lead to:
  • Distal radioulnar joint instability 3
  • Functional limitations and pain 4, 5
  • Poor hand function if left uncorrected 4

Malunion Prevention

• Inadequate initial reduction or loss of reduction during non-operative treatment can result in symptomatic malunion requiring corrective osteotomy 4, 5, 6

• Corrective osteotomy for established malunion improves outcomes but rarely restores the limb to normal function 4

Adjunctive Interventions

Arthroscopic Evaluation

• Routine arthroscopic assistance during distal radius fixation is NOT recommended based on moderate evidence showing no difference in outcomes compared to fluoroscopic guidance alone 1

• Arthroscopy may diagnose more associated ligamentous injuries, but this does not translate to improved functional outcomes at 24-48 months 1

Post-Operative Rehabilitation

• Active finger motion exercises should begin immediately post-operatively (day 1) to prevent stiffness 7

• Wrist mobilization can be initiated at 1-3 weeks based on fracture stability 7

• Home exercise programs are equally effective as supervised physiotherapy for uncomplicated cases 1, 7

Common Pitfalls to Avoid

• Do not rely solely on age 65 as an absolute cutoff—functional demand is more important than chronological age for surgical decision-making 1

• Do not assume all surgical techniques are equivalent for all fracture patterns—while overall outcomes are similar, specific fracture types (e.g., volar rim fractures) may benefit from particular approaches 1

• Do not delay treatment decisions in younger, high-demand patients—accepting significant volar angulation in this population risks symptomatic malunion requiring more complex corrective surgery 4, 5, 6

• Do not restrict finger motion during immobilization—failure to encourage early finger exercises leads to severe stiffness requiring extensive therapy or surgery 7