From the Guidelines
A distal radius fracture requires operative treatment when it is unstable or significantly displaced, as indicated by the most recent and highest quality study 1. Surgery is typically indicated for fractures with dorsal angulation greater than 10-15 degrees, radial shortening exceeding 3mm, intra-articular step-off greater than 2mm, or comminution with instability. The following are key indications for operative treatment:
- Dorsal angulation greater than 10-15 degrees
- Radial shortening exceeding 3mm
- Intra-articular step-off greater than 2mm
- Comminution with instability
- Open fractures
- Fractures with associated neurovascular compromise
- Fractures with carpal instability The most common surgical approaches include:
- Open reduction internal fixation (ORIF) with volar locking plates
- Percutaneous pinning
- External fixation
- A combination of these techniques The choice of procedure depends on:
- Fracture pattern
- Bone quality
- Patient age
- Functional demands Surgery aims to restore anatomical alignment, articular congruity, and radial length to prevent complications like malunion, post-traumatic arthritis, and functional limitations, as supported by the American Academy of Orthopaedic Surgeons/American Society for Surgery of the Hand clinical practice guideline summary management of distal radius fractures 1. Post-operatively, patients typically require immobilization for 1-2 weeks followed by progressive rehabilitation to restore wrist motion and strength. Early surgical intervention (within 2 weeks) generally produces better outcomes by allowing earlier mobilization and reducing stiffness, as noted in the acr appropriateness criteria for acute hand and wrist trauma 1.
From the Research
Indications for Operative Intervention
- Operative intervention for distal radius fractures is typically reserved for patients with displaced fractures that may result in bothersome compromises in function, considering patient-specific factors such as age, activity level, and preference 2.
- The decision to operate is based on the severity of the fracture, desired functional outcome, and patient comorbidities 3.
Operative Management Options
- Surgical management options include closed reduction and application of a cast, percutaneous K-wires, open reduction and internal fixation with plates, or external fixation 3.
- Volar locking plates (VLPs), Kirschner-wire fixations, and external fixations (EFs) are compared in terms of functional outcomes, radiological outcomes, and complications for distal radius fractures in patients aged 60 years and older 4.
Complications and Outcomes
- Operative management is associated with earlier improvement in function but exposes the patient to the risk of anesthesia and surgery, with potential complications such as complex regional pain syndrome, carpal tunnel syndrome, and infections 2, 4, 5.
- Non-operative management can result in good outcomes, especially in older adults, but may be associated with a higher rate of secondary procedures 5.
- The choice of operative management should consider the surgeon's familiarity with the implant design and its limitations, as well as the patient's individual needs and preferences 6.