What is the optimal management approach for a fracture of the distal end of the radius?

From the Guidelines

The management of distal radius fractures should prioritize anatomic restoration through surgical intervention for unstable or displaced fractures, while considering patient characteristics, age, and functional demands. The decision between conservative and surgical management is crucial, as it directly impacts morbidity, mortality, and quality of life outcomes. For stable, non-displaced fractures, conservative treatment with cast immobilization for 4-6 weeks is recommended 1. However, for unstable or displaced fractures (>2mm articular step-off, >10° dorsal angulation, or >3mm radial shortening), surgical intervention is typically necessary. The primary surgical options include closed reduction with percutaneous pinning, external fixation, or open reduction internal fixation (ORIF) with volar locking plates. ORIF with volar locking plates has become the preferred method for many unstable fractures as it allows for early mobilization and better restoration of anatomy 1.

Some key considerations in the management of distal radius fractures include:

• Fracture pattern and displacement
• Patient age and functional demands
• Bone quality and comorbidities
• The use of arthroscopic assistance during operative treatment, which has been updated to moderate evidence not in support of its use 1
• The importance of post-operative rehabilitation, including a short arm splint and progressive range of motion exercises

Complications to monitor include malunion, hardware irritation, tendon rupture, and complex regional pain syndrome. Elderly patients with low functional demands may tolerate greater deformity with acceptable functional outcomes, while younger, active patients typically benefit from anatomic restoration through surgical intervention to prevent long-term complications like post-traumatic arthritis and functional limitations 1.

In terms of specific treatment recommendations, ORIF with volar locking plates is a preferred method for many unstable fractures, as it allows for early mobilization and better restoration of anatomy. Additionally, the use of a home exercise program and supervised therapy following treatment is recommended, although the evidence to support its use remains inconsistent 1. Overall, the management of distal radius fractures requires a comprehensive approach that considers patient characteristics, fracture pattern, and treatment options to optimize outcomes and minimize complications.

From the Research

Management of Distal End Radius Fractures

• The decision to manage distal radius fractures conservatively or surgically depends on various factors, including the stability of the fracture, patient age, and comorbidities 2.
• Conservative treatment with reduction and immobilization can be effective for patients with stable fractures or those who are at high surgical risk 2.
• A study found that patients with significant comorbidities, high surgical risk, low functional requirements, and low cosmetic expectations may be suitable for conservative treatment 2.
• The use of three-dimensional printed splints for distal radius fractures may offer more comfort and be more environmentally friendly compared to traditional plaster casts 3.
• A shorter period of immobilization, such as one week, may be safe for non- or minimally displaced distal radius fractures and can lead to better functional outcomes and faster reintegration into daily activities 3.

Comparison of Treatment Modalities

• A study compared the clinical and radiological outcomes of patients treated with closed reduction and casting, open reduction and plating, and external fixation for intra-articular distal radius fractures 4.
• The results showed that there was no statistically significant difference in Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) scores between the groups, but there were significant differences in radiological parameters 4.
• Volar locking plate fixation was found to be superior to conservative treatment and external fixation in terms of radiological parameters such as joint stepping, radial inclination, and ulnar variance 4.

Principles of Conservative Treatment

• The principles of successful conservative treatment include precise reduction and stable retention in a plaster splint, close monitoring by biplanar radiography, and physiotherapy and ergotherapy starting after 2 weeks of treatment 5.
• The total duration of immobilization is typically 4 weeks, and the plaster splint is changed to a circular cast approximately 11 days after the traumatic event 5.
• A study found that conservative treatment can be effective for patients with stable fractures or those who are multimorbid and in poor general condition, with a low rate of complications 2.