Management of Distal Radius Fractures
Initial Imaging Approach
Obtain a standard 3-view radiographic series (posteroanterior, lateral, and 45° semipronated oblique) as your initial imaging for all suspected distal radius fractures. 1, 2 Two-view examinations miss a significant proportion of fractures, and the oblique view is critical for detecting fracture patterns that may be occult on standard PA and lateral views alone.
- When initial radiographs are equivocal but clinical suspicion remains high, obtain CT without IV contrast to better characterize intra-articular extension and comminution. 1, 2 CT is superior to plain radiographs for detecting articular involvement and is essential for surgical planning in complex fractures.
Decision Algorithm: Operative vs. Nonoperative Management
Indications for Surgical Fixation
Proceed with operative fixation if ANY of the following radiographic criteria are present:
- Articular step-off ≥2 mm 1, 3 — This is an absolute threshold, as residual articular incongruity beyond 2 mm leads to post-traumatic osteoarthritis
- Radial shortening >3 mm 1
- Dorsal tilt >10° 1
- Intra-articular displacement present 1
- Coronally oriented fracture line (longhorn sign) 1, 2
- Die-punch depression 1, 2
- More than three articular fracture fragments 1
Criteria for Nonoperative Cast/Splint Management
Use rigid cast immobilization (NOT removable splints) for displaced fractures that meet ALL of the following:
- Articular step-off <2 mm 1
- Radial shortening ≤3 mm 1
- Dorsal tilt ≤10° 1
- Minimal to no displacement 1
- No comminution or <3 articular fragments 1
For minimally displaced fractures meeting these criteria, removable splints are acceptable. 4, 1 However, for displaced fractures requiring closed reduction, rigid immobilization is preferred over removable splints (moderate recommendation strength). 4
Nonoperative Treatment Protocol
- Initiate immediate active finger motion exercises following diagnosis to prevent stiffness. 1 Finger motion does not adversely affect adequately stabilized distal radius fractures.
- Obtain follow-up radiographs at approximately 3 weeks and at cessation of immobilization to confirm maintenance of reduction. 4, 1
- Consider vitamin C supplementation for prevention of complex regional pain syndrome. 1
Surgical Considerations for Intra-articular Fractures
When operating on intra-articular fractures, arthroscopic evaluation of the articular surface is an option to improve diagnostic accuracy. 4 Arthroscopy can identify associated ligament injuries (scapholunate, lunotriquetral, or TFCC tears) not detectable on standard radiographs. 4
- Surgical treatment of associated ligament injuries at the time of radius fixation is an option (weak recommendation strength). 4 However, functional differences at 1-2 years postoperatively are not clinically relevant regardless of whether ligament injuries are addressed arthroscopically.
- The goal of operative fixation is to restore the articular surface to <2 mm step-off to prevent post-traumatic osteoarthritis. 1, 3
Critical Pitfalls to Avoid
- Underestimating articular involvement leads to post-traumatic arthritis—the 2 mm threshold is absolute and non-negotiable. 1, 3 Even small articular incongruities result in accelerated joint degeneration.
- Failure to obtain adequate radiographic views (minimum 3 views) may lead to missed intra-articular extension. 1, 2 The oblique view is essential and cannot be omitted.
- Do not use removable splints for displaced fractures requiring reduction—rigid immobilization is necessary to maintain alignment. 4
When Conservative Management Fails
Immediate surgical referral is indicated if follow-up radiographs demonstrate loss of reduction with any parameter exceeding the operative thresholds listed above. 1 Loss of alignment is common in the first 3 weeks, making serial radiographic monitoring essential.