Treatment of Displaced Distal Radial Fractures in Adults
For displaced distal radius fractures in adults, initial management should include closed reduction and immobilization, with surgical fixation strongly considered when post-reduction radiographs show radial shortening >3mm, dorsal tilt >10°, or intra-articular displacement. 1
Initial Assessment and Reduction
Upon presentation, immediately obtain radiographs to evaluate:
- Degree of displacement (>3mm is significant) 1
- Dorsal or volar tilt (>10° is unacceptable) 1
- Intra-articular involvement 1
- Associated injuries to median nerve, ulnar styloid, or distal radioulnar joint 2
Perform closed reduction and splinting as the initial treatment for all displaced fractures. 3 Post-reduction radiographs are mandatory to determine if acceptable alignment has been achieved. 1
Decision Point: Operative vs Non-Operative Management
Indications for Surgical Fixation
Proceed with surgical intervention if post-reduction imaging demonstrates any of the following: 1
- Radial shortening >3mm
- Dorsal tilt >10°
- Intra-articular displacement or step-off
- Persistent median nerve dysfunction after reduction (may require decompression) 1
Surgical Options
The AAOS/ASSH guidelines acknowledge multiple surgical techniques without strongly favoring one over another, though volar locking plates have become increasingly utilized. 4 Options include:
- Volar locking plate fixation (most common, excellent for sagittal plane correction) 5
- Percutaneous K-wire fixation 4, 2
- External fixation 4, 2
- Open reduction and internal fixation with plates 2, 6
Non-Operative Management
Cast immobilization is appropriate when post-reduction alignment meets acceptable parameters (radial shortening ≤3mm, dorsal tilt ≤10°, no significant intra-articular displacement). 1 This approach can yield good functional outcomes, particularly in elderly patients with lower functional demands. 3
Special Considerations for Elderly Patients (≥65 Years)
The evidence presents nuanced findings for older adults. While operative management achieves superior radiographic outcomes at all time points, functional differences are less pronounced. 3 At one year, there is no significant difference in Disabilities of the Arm, Shoulder and Hand (DASH) scores or pain between operative and non-operative groups, though operative patients maintain better grip strength. 3
However, operative management carries higher complication rates: 7
- Overall 1-year complication rate: 307.5 per 1,000 fractures (operative) vs 236.2 per 1,000 (non-operative)
- Stiffness: 16.0% (operative) vs 9.8% (non-operative)
- Complex regional pain syndrome: 9.9% (operative)
- Median neuropathy: 8.0% (operative)
- Implant-related complications: 3.8% (operative)
- Tendon rupture: 2.8% (operative)
For elderly patients with acceptable post-reduction alignment and lower functional demands, non-operative management is reasonable despite minor limitations in range of motion. 3 For active, independent elderly patients with unacceptable alignment, surgical fixation remains appropriate. 6
Post-Treatment Protocol
Immobilization Duration
- Maintain immobilization for approximately 3 weeks 1
- Obtain radiographic follow-up at 3 weeks and at immobilization removal to confirm healing 1
Early Mobilization
Initiate active finger motion exercises immediately following diagnosis or surgery to prevent stiffness, which is the most functionally disabling complication. 1 Finger motion does not adversely affect adequately stabilized fractures. 1 Early wrist motion is not routinely necessary following stable fixation. 1
Adjunctive Treatments
- Vitamin C supplementation for prevention of complex regional pain syndrome (moderate recommendation strength) 1
- Ultrasound and/or ice as adjuvant options (weak evidence) 1
Critical Pitfalls to Avoid
- Do not accept residual radial translation in the coronal plane, as this contributes to distal radioulnar joint instability and ongoing pain. 5 Standard volar locking plates do not inherently correct this deformity and require specific attention during reduction. 5
- Do not miss associated median nerve compression, which is the most common complication and may require decompression if persistent after reduction. 1, 2
- Monitor for complications during immobilization (skin irritation, muscle atrophy occur in 14.7% of cases). 1
- In elderly patients, carefully weigh surgical risks against functional benefits, as minor motion limitations may not significantly impact daily function. 3, 7