What is the acceptable amount of volar tilt in an adult patient with a distal radius fracture?

Acceptable Volar Tilt in Distal Radius Fractures

For adult patients under 65 years, post-reduction dorsal tilt >10 degrees (equivalent to volar tilt <-10 degrees) is an indication for operative fixation, while the target for anatomic restoration is approximately 5-11 degrees of volar tilt. 1

Age-Based Treatment Thresholds

Non-Geriatric Adults (Under 65 Years)

• The American Academy of Orthopaedic Surgeons recommends operative fixation when dorsal tilt exceeds 10 degrees post-reduction, as this threshold is supported by moderate evidence showing surgical intervention improves both radiographic and patient-reported outcomes 1

• Successful treatment requires restoration of volar tilt along with radial length, inclination, and articular alignment 2

• Target volar tilt after fixation should be 5-11 degrees, based on multiple surgical series demonstrating optimal functional outcomes within this range 3, 4, 5

Geriatric Patients (≥65 Years)

• Strong evidence shows operative treatment does not improve long-term patient-reported outcomes in geriatric patients despite achieving better radiographic parameters 1

• Radiographic parameters including volar tilt show weaker correlation with functional outcomes in this population 1

• Consider functional demand over chronologic age, as the 65-year threshold serves as a proxy for activity level rather than an absolute cutoff 1

Radiographic Targets for Operative Fixation

When surgical intervention is pursued, the following parameters represent anatomic restoration:

• Volar tilt: 5-11 degrees (studies report mean final values of 5°, 7.11°, 10.8°, and 11.5° across different fixation techniques) 3, 4, 6, 5

• Radial inclination: 20-25 degrees 7, 3, 4

• Radial length: within 1-2 mm of ulnar variance 7, 3, 5

• Articular step-off: <2 mm 2

Critical Clinical Pitfalls

• Do not apply adult radiographic thresholds to pediatric patients, as children have superior remodeling capacity and different acceptable alignment parameters 1, 8

• Dorsal tilt (negative volar tilt) >10 degrees is generally unacceptable in non-geriatric adults and requires operative intervention 1, 7

• Obtain radiographs at 1-2 weeks post-reduction to detect early loss of reduction, as this timing is critical for identifying re-displacement requiring intervention 9, 8

• Ensure proper lateral radiograph technique to accurately assess volar/dorsal angulation, as inadequate imaging can lead to missed malalignment 9

Operative Indications Beyond Volar Tilt

Additional factors warranting surgical fixation include:

• Articular step-off >2 mm 2
• Radial shortening >3 mm 9
• Coronally oriented fracture line, die-punch depression, or >3 articular fragments 2