Evaluation and Management of Adult Distal Radius Fractures
Initial Evaluation
Obtain standard 3-view radiographs (PA, lateral, and 45° semipronated oblique) to assess fracture pattern, displacement, and articular involvement. 1
Key Radiographic Parameters to Measure:
- Radial shortening (normal <3 mm)
- Dorsal/volar tilt (normal volar tilt 0° to +10°)
- Intra-articular step-off (measure in millimeters)
- Radial inclination
- Articular comminution (count fragments, assess for die-punch depression) 2, 3
Physical Examination Priorities:
- Assess for median nerve compression (carpal tunnel syndrome is common)
- Evaluate distal radioulnar joint (DRUJ) stability
- Check for associated injuries to carpus, ulnar styloid, or soft tissues
- Document neurovascular status distally 4, 5
Treatment Algorithm Based on Age and Fracture Characteristics
For Active Patients <65 Years with Displaced, Unstable, Intra-articular Fractures:
Proceed with surgical fixation if post-reduction radiographs show ANY of the following:
Additional operative indications include:
- Coronally oriented fracture lines
- Die-punch depressions (closed reduction achieves anatomic alignment in only 49% of cases)
- More than 3 articular fragments 2
For Patients ≥65 Years:
Non-operative management with closed reduction and immobilization is appropriate for most patients, as surgical fixation does not improve long-term patient-reported outcomes despite achieving better radiographic alignment. 2, 3
Base treatment decisions on functional demand and patient values rather than chronologic age alone—the 65-year threshold is merely a proxy for activity level. 2, 3
Surgical Fixation Method
Use volar locked plating for active patients requiring rapid functional recovery, as it provides superior short-term function at 3 months compared to other techniques. 2
All fixation methods (volar plates, dorsal plates, external fixation, percutaneous pinning) produce equivalent outcomes at 1 year for complete articular or unstable fractures. 2
Surgical Goals:
- Restore radial length to within normal (avoid shortening >3 mm)
- Achieve volar tilt of 0° to +10° (avoid dorsal tilt >10°)
- Reduce articular step-off to ≤1–2 mm (this is critical to prevent post-traumatic arthritis) 2, 1, 3
Non-Operative Management
For fractures meeting criteria for non-operative treatment:
- Perform closed reduction under hematoma block, procedural sedation, or Bier block 6
- Immobilize in well-molded cast or splint
- Obtain post-reduction radiographs to confirm acceptable alignment 4
Common pitfall: Up to 50% of patients are at risk of losing reduction, and 20-50% may ultimately require surgical fixation. 6
Post-Treatment Radiographic Surveillance
Obtain plain radiographs at 2 weeks after surgery or reduction; thereafter, image only when clinically indicated (new trauma, pain >6/10, loss of range of motion, or neurovascular symptoms). 2
The frequency of routine imaging does not affect outcomes, but an early 2-week film helps detect loss of reduction. 2
Rehabilitation and Pain Management
Hand Therapy:
Supervised hand therapy is not routinely required for all patients—reserve it for complex injuries or patients with limited functional recovery. 2
Instruct all patients to perform active finger range-of-motion exercises immediately following diagnosis to prevent finger stiffness, which is one of the most functionally disabling complications. 4
A home exercise program is an appropriate option for most patients when proper instruction is provided. 4, 2
Analgesia:
Implement a multimodal, opioid-sparing pain protocol (acetaminophen, NSAIDs when not contraindicated, regional blocks). 2
Limit opioid prescriptions to the minimum necessary to reduce risk of opioid use disorder and related mortality. 2
Special Considerations
DRUJ Instability:
Obtain a true lateral radiograph of the carpus post-reduction to assess DRUJ alignment. 4
While concurrent surgical treatment of DRUJ instability may be considered, evidence is insufficient to make a definitive recommendation. 4
Unremitting Pain During Follow-up:
Reevaluate any patient with persistent pain during follow-up, as this may indicate complications such as complex regional pain syndrome, median neuropathy, loss of reduction, or developing arthritis. 4, 7
Remote Injuries:
Patients with concurrent injuries elsewhere in the body have a 6-fold increased risk of complications after distal radius fracture treatment—factor this into counseling and decision-making. 7
Pediatric Considerations
Do not apply adult radiographic thresholds to pediatric patients, as children have superior remodeling capacity and different acceptable alignment parameters. 3
For pediatric physeal fractures presenting >10 days post-injury, avoid manipulation due to increased risk of physeal arrest. 8