Recommendations

Key Recommendations

The goal of treatment of distal radius fractures is restoration of anatomy and recovery of hand, wrist, and forearm function.

Whether the patient is being treated in a cast or a splint or is waiting for a surgical fixation, it is important that they start rehabilitation of the hand at the earliest opportunity; patient education, reassurance, and pain control are essential during the initial visit.

The affected limb needs to be elevated. Active range of motion of the fingers and shoulder should begin during the first few days after injury. This is to help control edema in the hand, and to prevent stiffness in the metacarpophalangeal (MCP) and proximal interphalangeal joints, and frozen shoulder.[46][47]

In all patients, following manual or surgical fracture reduction, if median nerve dysfunction is found to worsen or persists, a carpal tunnel release procedure should be performed urgently by an orthopedic surgeon.[48][49][50]

Initiating a bone mineral density workup in the orthopedic clinic can improve osteoporosis evaluation and treatment rates following fragility fractures of the distal part of the radius.[16][51]

Appropriate pain management is important, especially during rehabilitation; however, specific treatment varies widely depending on the patient, clinical presentation, method of treatment, and local treatment protocols. Opioid alternatives, both pharmacologic (e.g., local anesthetics, nonsteroidal anti-inflammatory drugs, acetaminophen) and nonpharmacologic (e.g., ice, elevation, compression, cognitive therapies) should be considered alongside opioid-sparing protocols when possible given the risks of opioid analgesics (adverse events, misuse, opioid use disorder, and diversion for nonmedical use).[35]

Ulnar styloid fractures often occur concurrently with distal radius fractures. They can usually be managed nonoperatively.[52]

Initial treatment prior to definitive care

Closed fractures

For closed fractures, initial treatment is immobilization.

Typically, a short arm cast may be used with free MCP joints and not extending beyond the distal palmar flexion crease. Noncircumferential splints are often used acutely in the emergency department due to the risk of swelling.

If the fracture is displaced, the patient will require reduction or referral to a center where this can be performed. Postreduction radiographs should be obtained in the splint. If reduction is inadequate or unstable, an open reduction and fixation is likely to be necessary.

All fractures should have adequate follow-up care to ensure timely care. For unstable fractures and those requiring fixation, immediate consultation with an orthopedic surgeon should be obtained (or with a specialist hand surgeon if available).

Open fractures

Open fractures require urgent treatment with saline irrigation and debridement of the fracture and open wound, and removal of all devitalized tissue as well as foreign debris, prior to fixation.[53]

Subsequently, if any delay in definitive treatment is anticipated, the fracture may be provisionally stabilized via a splint or an external fixator.[16] The American Academy of Orthopaedic Surgeons (AAOS) recommends that patients with open fractures are brought to the operating room for debridement and irrigation as soon as reasonable, and ideally within 24 hours post injury.[44][54] Preoperative antibiotics are recommended to prevent surgical site infections in operative treatment of open fractures.[44][54] In patients with major extremity trauma undergoing surgery, the AAOS strongly recommends antibiotic prophylaxis with systemic cefazolin or clindamycin, except for open fractures that are Type III (an open segmental fracture, or an open fracture with extensive soft tissue damage, or a traumatic amputation) and possibly Type II (laceration greater than 1 cm long without extensive soft tissue damage, flaps, or avulsions), for which additional gram-negative coverage (e.g., piperacillin/tazobactam) is preferred.[44][54][55]

However, local sensitivities and protocols should be followed for antibiotic selection. In patients with major extremity trauma undergoing surgery, local antibiotic prophylactic strategies, such as vancomycin powder, tobramycin-impregnated beads, or gentamicin-covered nails, may be beneficial, when available.[44][54]

One study suggests that open fractures should be debrided within 6 hours of injury.[56] Another prospective study concludes that time to irrigation and debridement does not affect the development of local infections, provided it is performed within 24 hours of arrival to the emergency department.[57] One systematic review reports that early debridement of open fractures by an experienced team within 24 hours is adequate.[53]

Should contamination be a concern, it is prudent to perform irrigation and debridement, and to provisionally stabilize the fracture via an external fixator.[44][54]

For treatment of infections, antibiotics should be administered according to the type of open injury and severity of contamination at the time of diagnosis.[44][53] However, local sensitivities and protocols should be followed for antibiotic selection.

After the infection is controlled, a formal open reduction and internal fixation may be performed at a later stage.[54]

Monitoring for median nerve function should be maintained throughout the postoperative period.

Nondisplaced fractures of distal radius

Patients with nondisplaced fractures of the distal radius usually have sustained low-energy injuries and are largely comfortable once the wrist is immobilized.

The choice of immobilization may vary from a cast applied by the surgeon or a cast technician, to a custom-made splint from an occupational therapist.

Short arm casts made of plaster of Paris or fiberglass are applied distal to the elbow and in nondisplaced fractures maintain the position of the wrist at neutral.[16]

The thumb is free and the cast terminates at the level of the distal palmar flexion crease. This allows free motion of the MCP joints, thus maintaining digital mobility as the fracture heals, and minimizes post-traumatic stiffness.

Casts should be well fitting, and well padded to avoid any pressure effects, and the patient must be alerted to the possibility of needing a cast change. Cast changes may be necessary if the cast gets loose as the initial post-traumatic swelling reduces. Cast immobilization for a period of 3-4 weeks is safe.[16][58][59]

Alternatively, in patients unable to tolerate casts or unwilling to wear a cast, or in patients who have an incomplete fracture of the distal radius, a forearm-based splint holding the wrist at neutral may be used.[60]

Splints are custom-made by occupational therapists, and can be custom-molded to the patient's anatomy. As swelling reduces, modification to fit the changing dimensions of the patient's limb may be necessary.

Patients with nondisplaced fractures or incomplete crack fractures of the radius must be cautioned about the possibility of spontaneous rupture of the extensor pollicis longus (EPL) tendon. This is a rare complication with an incidence of 5% or less, and tends to occur within the first 12 weeks after injury and is usually preceded by increasing pain over the dorsal aspect of the distal radius.[61] Not all EPL ruptures are symptomatic and not all necessarily need to be treated. [Figure caption and citation for the preceding image starts]: Cast treatment of a distal radius fractureFrom the collection of Dr Chaitanya S. Mudgal [Citation ends].Cast treatment of a distal radius fracture

Closed displaced fracture of distal radius

Restoration of anatomy is essential in an effort to maximize functional outcome. In the initial stages this may be achieved by a manipulative reduction, and thereafter formal treatment is planned.

Analysis of fracture geometry is aided by post-reduction radiographs, and if necessary a computed tomography scan may be obtained. These radiographic investigations offer clues to the stability or instability of the fracture and help guide its definitive treatment.

Manipulative reduction in the acute setting is most often performed using a hematoma block (instillation of a local anesthetic within the fracture hematoma), and distraction of the fracture site aided by finger traps.[62][63][64] Diffusion of the anesthetic volarly around the median and ulnar nerves may occur, and patients should be reassured that digital numbness is to be expected. Conscious sedation may be used for reductions in the emergency department. Different fracture geometries require different reduction techniques; for example, a dorsally angulated fracture can be reduced by applying dorsal pressure to the distal fragment to "milk" it back into position. 

Adequate reduction is verified by palpation for step-offs along the dorsal and radial surfaces. The fracture is then held in its reduced position in a well-molded splint. Postreduction radiographs should be obtained with the splint in place.

If the patient is an unsuitable candidate for prolonged casting or inadequate reduction is observed on imaging following manual reduction, surgical reduction and fixation should be considered.

The decision about whether a surgical intervention is warranted should be discussed between the patient and surgeon. Strong evidence suggests no significant difference in radiographic or patient-reported outcomes between fixation techniques for complete articular or unstable distal radius fractures, although volar locking plates lead to earlier recovery of function in the short term (3-6 months), and outcomes equalize within 1 year of injury.[35][65] One randomized controlled trial involving 90 patients (46 in the nonoperative group and 44 in the operative group) found that 28% of nonoperatively managed patients had a subsequent surgical procedure.[65] Another randomized controlled trial reported that patients with an acceptably reduced extra-articular distal radial fracture treated with open reduction and volar plate fixation have better functional outcomes after 12 months compared with nonoperatively managed patients. A total of 42% of nonoperatively managed patients had a subsequent surgical procedure.[66] Moderate evidence supports that for nongeriatric patients (most commonly defined in studies as under 65 years of age), operative treatment for fractures with post-reduction radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement or step off >2 mm leads to improved radiographic and patient-reported outcomes.[35]

Strong evidence suggests that operative treatment for geriatric patients (most commonly defined in studies as 65 years of age and older) does not lead to improved long-term patient-reported outcomes compared with nonoperative treatment.[35]

Following volar plate fixation, patients can be safely treated with a pressure bandage.[67] Some surgeons prefer a cast for pain management. However, this period should not be longer than 3 weeks.[68]

In older patients with low functional demands, the presence of deformity does not preclude good functional outcomes.[69] Monitoring for median nerve function should be maintained throughout the postoperative period. [Figure caption and citation for the preceding image starts]: Plate fixation after open reduction with a volarly placed plate and screwsFrom the collection of Dr Chaitanya S. Mudgal [Citation ends].Plate fixation after open reduction with a volarly placed plate and screws​ There is no apparent treatment benefit for the use of wrist arthroscopy at the time of distal radius fracture fixation.[35][70][71]

Open displaced fracture of distal radius

Open distal radius fractures are rare injuries.[72] In most situations, open fractures constitute a surgical emergency and operative treatment at the earliest possible opportunity is the preferred method of management.

In patients who may have significant comorbidities or other injuries, a thorough evaluation of the risk of urgent operative intervention is critical, and is guided by a comprehensive discussion with other medical teams as well as the anesthesia team.

Fractures are often provisionally reduced in the emergency department in anticipation of delay in getting the patient into the operating room. This helps to reduce deformity and soft-tissue swelling, and may relieve any symptoms of nerve compression. Open reduction and internal fixation is performed in the operating room. Thorough saline irrigation and debridement of the fracture and the open wound is required prior to fixation.[44][53][54] Should contamination be a concern and if there is a high concern for infection, internal fixation may be delayed or external fixation may be utilized as definitive treatment.[44][54][72]

Ongoing antibiotic therapy should be administered according to the type of open injury and severity of contamination at the time of diagnosis.[44] In most centers, the specific regimen is best decided upon with infectious disease colleagues, taking local sensitivities into account.

Tetanus prophylaxis may need to be considered, depending on the patient's tetanus vaccination history.[73]

Most open fractures are high-energy injuries and there is a low threshold to perform concomitant carpal tunnel release. Such injuries may be accompanied by significant soft-tissue trauma. It is not uncommon for these patients to present with very swollen and tense forearms. In these patients it is mandatory to evaluate for forearm compartment syndrome. If there are obvious signs and symptoms of compartment syndrome, a clinical diagnosis is established and surgical fasciotomy is performed.[74] This is performed in the emergency department, and a compartment pressure >30 mmHg is diagnostic of a compartment syndrome (if the patient is normotensive). This is a surgical emergency and urgent fasciotomy, combined with open reduction and fixation of the fracture as well as release of the carpal tunnel, is critical to minimize adverse long-term effects. See Compartment syndrome of extremities.

Nondisplaced fracture of the scaphoid

Isolated nondisplaced scaphoid fractures can be treated nonoperatively in most patients, with high union rates and good clinical outcomes.[75][76]

Patients are placed in a forearm-based cast without incorporating the thumb. There is no universal consensus on the duration of casting, but usually the cast is maintained for a total of 8-12 weeks or until the fracture is healed.[77]

Patients with proximal pole fractures, those with fracture displacement, or those who are unwilling to accept the protracted duration of casting are considered candidates for percutaneous screw fixation or for open reduction and internal fixation of the scaphoid.[78][79]

Fractures of the distal radius with associated injury to carpus or carpal ligaments

Concomitant carpal bone, ligament injuries, or triangular fibrocartilage complex (TFCC) lesions may adversely impact outcome in patients with fractures of the distal radius.[2][80][81] Fracture patterns in which the fracture line of the distal radius exits on the scapholunate crest of the articular surface are particularly prone to injuries of the scapholunate interosseous ligament.

Evidence suggests that distal radius fracture without concomitant ligament injury is rare. Arthroscopic studies report the incidence of concomitant scapholunate ligament (SL) and TFCC injury as 78% and 54% respectively in patients with distal radius fracture.[82][83][84]

Two prospective 13- to 15-year follow-up studies of patients with untreated complete (grade 3) or partial (grade 1 or 2) SL tears and TFCC tears associated with displaced distal radius fracture found no major differences in the subjective, objective, or radiographic outcomes for patients with SL injuries. However, none of the patients had a grade 4 tear, and only one patient with a TFCC tear required an operation for painful instability since the fracture.[82][83] The TFCC tear study concluded that there was insufficient evidence that TFCC tear at the time of distal radius fracture would influence the subjective long-term outcome.[83]

Use of this content is subject to our disclaimer