Management of Impacted Intra-articular Distal Radius Fractures
Volar locked plating is the recommended primary treatment for impacted intra-articular distal radius fractures, providing superior functional outcomes and earlier return to function compared to conservative management. 1
Initial Assessment
Evaluate the fracture for:
- Degree of articular displacement (>3mm displacement or >10° dorsal tilt indicates significant displacement requiring surgical intervention) 1
- Joint congruity and stability to determine treatment approach 1
- Consider CT scanning to improve diagnostic accuracy for complex intra-articular fractures 1
Treatment Algorithm
Surgical Management (Preferred)
Volar locked plating is the primary surgical option for comminuted intra-articular fractures, offering: 1, 2
- Earlier wrist mobilization 1
- Better range of movement 1
- Less pain and disability 1
- Early return of function (particularly at 3 months) 3
Alternative fixation methods (dorsal plating, external fixation, percutaneous pinning) show no significant difference in long-term outcomes, though volar locked plating demonstrates superior short-term functional recovery 3, 2
Arthroscopic Assistance
Arthroscopic-assisted reduction is optional but not routinely necessary: 3, 1
- The AAOS guideline provides moderate evidence against routine arthroscopic assistance, as fluoroscopic guidance alone achieves equivalent outcomes at 48 months 3
- May be considered for improved diagnostic accuracy and treatment of associated ligament injuries 1
- Can identify and address intracarpal soft tissue injuries not apparent on plain radiographs 4
Conservative Management
Conservative management is NOT recommended for comminuted intra-articular fractures due to risk of joint incongruity and subsequent post-traumatic arthritis 1
Adjunctive Treatments
- Bone grafting may be necessary for severely comminuted fractures with significant bone voids, though evidence regarding outcomes remains inconclusive 1
- Associated ligament injuries can be evaluated and treated at the time of radius fixation 1
Postoperative Management
Immediate Postoperative Care
- Active finger motion exercises should begin immediately following surgery to prevent stiffness, which is the most functionally disabling complication 1, 2
- Early wrist motion is not routinely necessary following stable fracture fixation 1
Radiographic Follow-up
- Obtain radiographs at approximately 3 weeks and at the time of immobilization removal to confirm adequate healing 1, 2
- The AAOS guidelines indicate no difference in outcomes based on frequency of radiographic evaluation 2
Pain Management
Utilize multimodal and opioid-sparing protocols when possible: 2
- Local anesthetics 2
- Nonsteroidal anti-inflammatory agents 2
- Acetaminophen 2
- Non-pharmacologic interventions 2
Key Clinical Pitfalls
- Avoid conservative management for displaced intra-articular fractures, as this leads to joint incongruity and arthritis 1
- Joint stiffness is the most functionally disabling adverse effect—emphasize early finger motion 1, 2
- Immobilization-related complications occur in approximately 14.7% of cases, including skin irritation and muscle atrophy 2
- Careful screw length measurement during volar plating is essential to minimize postoperative tendon irritation 5