In an active patient with a displaced, unstable, intra‑articular distal radius fracture (or neurovascular compromise), what are the surgical indications, optimal timing, preferred fixation method, target radiographic goals (radial length ≥9–10 mm, radial inclination ≥15°, volar tilt 0°–+10°, articular step‑off ≤2 mm), and postoperative management including immobilization duration, weight‑bearing restrictions, analgesia, antibiotic prophylaxis, and special considerations for osteoporosis, diabetes, and smoking?

Surgical Management of Displaced, Unstable, Intra-articular Distal Radius Fractures

Surgical Indications

For active patients under 65 years with displaced, unstable, intra-articular distal radius fractures, proceed with surgical fixation when post-reduction imaging shows radial shortening >3mm, dorsal tilt >10 degrees, or intra-articular displacement/step-off >2mm. 1

• Age 65 serves as a proxy for functional demand rather than an absolute cutoff—prioritize patient-centered discussion about activity level, values, and functional requirements over chronologic age alone 1
• For patients >65 years, strong evidence demonstrates surgical fixation does not improve long-term patient-reported outcomes compared to non-operative treatment, despite better radiographic parameters 1
• Neurovascular compromise represents an absolute indication for urgent surgical intervention regardless of age 2

Critical Pitfall to Avoid

• Do not use removable splints for displaced, comminuted, or unstable fractures—these are only appropriate for stable, minimally displaced buckle fractures 3, 2
• Comminuted fractures require rigid cast immobilization if managed non-operatively, as they are inherently unstable and will lose reduction with inadequate immobilization 3

Optimal Surgical Timing

• Perform surgery urgently (within hours) for open fractures, compartment syndrome, or acute neurovascular compromise 4
• For closed fractures without neurovascular compromise, surgery within 1-2 weeks is standard practice, allowing time for soft tissue swelling to resolve while preventing early malunion 4

Preferred Fixation Method

Choose volar locked plating for active patients requiring faster functional recovery, as it provides superior short-term function at 3 months compared to other techniques, though all fixation methods yield equivalent outcomes at 1 year. 1

• Strong evidence shows no difference in long-term outcomes between fixation techniques (volar plates, dorsal plates, external fixation, percutaneous pinning) for complete articular or unstable distal radius fractures 1
• Volar locked plating demonstrates earlier functional recovery with better Disabilities of the Arm, Shoulder and Hand (DASH) scores at 6 weeks (27 vs 53), 9 weeks (17 vs 39), and 12 weeks (11 vs 26) compared to percutaneous fixation 5
• For severely comminuted patterns, consider spanning external fixation or fragment-specific fixation techniques 3
• Percutaneous pinning with casting or external fixation remains acceptable for patients not requiring rapid return to function 1, 5

Target Radiographic Goals

Achieve the following parameters to optimize functional outcomes and minimize post-traumatic arthritis:

• Radial length: Restore to within normal (avoid shortening >3mm) 1, 2
• Radial inclination: ≥15° 6
• Volar tilt: 0° to +10° (avoid dorsal tilt >10°) 1, 6
• Articular step-off: ≤1-2mm (operative threshold is >2mm displacement) 1, 7, 6

Intraoperative Imaging Technique

• Use fluoroscopy with 30° cephalad posteroanterior views and 22° lateral views to optimally visualize articular surface reduction 7
• Consider CT scanning postoperatively if plain radiographs are insufficient to assess articular congruity, particularly for complex intra-articular patterns 7

Postoperative Management

Immobilization Duration

• Volar locked plating allows early wrist mobilization at 2-3 weeks, though early motion is not routinely necessary for stable fixation 2
• For percutaneous fixation or external fixation, maintain immobilization for 6 weeks 5
• Initiate active finger motion exercises immediately postoperatively to prevent stiffness—this does not adversely affect adequately stabilized fractures 3, 2

Radiographic Follow-up

• Obtain radiographs at 2 weeks postoperatively, then as clinically indicated rather than routine serial imaging 1
• No difference exists in outcomes based on frequency of radiographic evaluation, though consider imaging at 2 weeks to detect early loss of reduction 1
• Obtain films only for new trauma, pain score >6/10, loss of range of motion, or neurovascular symptoms 1

Weight-bearing Restrictions

• Avoid weight-bearing through the affected wrist for 6 weeks minimum to allow fracture healing 4
• Progress weight-bearing gradually based on radiographic evidence of healing and patient symptoms 4

Analgesia

• Implement multimodal, opioid-sparing pain protocols whenever possible 1
• Consider acetaminophen, NSAIDs (if not contraindicated), and ice application at 3 and 5 days post-injury for symptomatic relief 2
• Limit opioid prescriptions to minimize risk of opioid use disorder and prescription-related mortality 1
• Consider vitamin C supplementation for prevention of complex regional pain syndrome (moderate recommendation strength) 2

Antibiotic Prophylaxis

• Administer standard preoperative prophylaxis (typically cefazolin 2g IV within 60 minutes of incision) for open reduction and internal fixation 4
• Single-dose prophylaxis is sufficient for clean cases without additional risk factors 4

Special Considerations

Osteoporosis

• Osteoporotic bone increases risk of fixation failure—consider augmentation with bone graft or bone graft substitutes for metaphyseal voids 4
• Locked plating provides superior purchase in osteoporotic bone compared to conventional plates 4
• Address underlying osteoporosis with appropriate medical management postoperatively 4

Diabetes

• Diabetic patients have higher complication rates, though diabetes alone does not contraindicate surgery 8
• Optimize glycemic control perioperatively (HbA1c <8% ideally) to reduce infection risk 8
• Monitor closely for wound healing complications and infection 8

Smoking

• Smoking significantly increases postoperative complications including nonunion (higher rate in smokers), hardware removal, revision procedures, wrist stiffness, and persistent distal radius tenderness 8
• Overall complication rate is 9.8% in smokers versus 5.6% in nonsmokers 8
• Counsel patients on smoking cessation preoperatively and document continued smoking as a risk factor for complications 8
• These increased complication rates persist even when controlling for confounding variables like diabetes and obesity 8

Hand Therapy

• Supervised hand therapy is not routinely necessary for all patients, though specific subsets may benefit 1
• Active range of motion exercises can be self-directed for most patients with adequate instruction 1, 2