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Distal radius fractures in adults

Distal radius fractures in adults
Literature review current through: Jan 2024.
This topic last updated: Oct 31, 2023.

INTRODUCTION — The distal radius is the most common fracture site in the upper extremity. Such injuries account for approximately one-sixth of fractures treated in United States emergency departments (EDs) [1]. Familiarity with wrist anatomy and the natural history of major fracture types is essential for appropriate management of distal radius fractures [2]. The evaluation and management of distal radius fractures in adults are reviewed here. Other wrist injuries are discussed separately. (See "Evaluation of the adult with acute wrist pain" and "Overview of carpal fractures".)

The management of severe upper extremity fractures, which can be associated with neurovascular injury, is reviewed separately. (See "Severe upper extremity injury in the adult patient" and "Surgical management of severe upper extremity injury".)

EPIDEMIOLOGY AND RISK FACTORS — A review of over 1.4 million United States emergency department (ED) visits found that hand and forearm fractures account for 1.5 percent of all visits [1]. Of these, fractures of the radius and/or ulna comprise the largest portion (44 percent).

The majority of distal radius fractures occur as isolated injuries in two distinct populations: youth involved in sport who sustain a relatively high-energy fall, and seniors with osteoporotic bone who sustain a low-energy fall.

Athletics — The mechanism for sustaining wrist fractures among young people varies according to the local popularity of different physical activities. A Scottish study of distal radius fractures related to sport found that football (ie, soccer) produced 50 percent of fractures [3]. Play on artificial turf increased the likelihood of fracture by a factor of five. Skiing, dancing, and rugby caused 12, 9, and 7 percent of wrist fractures, respectively. More severe injuries occurred as a result of skiing, horseback riding, and dancing.

The increasingly popular sport of snowboarding has a high rate of associated extremity fractures, including those of the distal radius. Physicians at a Japanese hospital caring for more than 10 ski areas evaluated over 5000 snowboarders for injuries [4]. They found most distal radius fractures occurred in patients in their 20s (82.3 percent) without extensive snowboarding experience (42 percent novices; 48 percent intermediates). Ninety-four percent of patients had not received professional instruction, and 87 percent were not wearing protective equipment. Although less likely to be injured, more experienced snowboarders were more likely to sustain a complex intraarticular fracture.

Older population — Age and sex both play a role in the risk of distal radius fracture. At 50 years of age, a White woman from the United States or Northern Europe has approximately a 15 percent lifetime risk of a distal radius fracture; a man in the same regions has a lifetime risk of just over 2 percent [5].

One large, prospective study of distal radius fractures among White American women with osteoporosis, over the age of 65, involved in low-energy falls, found three statistically significant, independent risk factors: decreased bone density at the distal radius (relative risk [RR] = 1.8), a history of recurrent falls (RR = 1.6), and previous fragility fracture after age 50 (RR = 1.3) [6]. For women over 75 years of age, dementia was an additional risk factor. Use of oral estrogen was found to be protective, and intraarticular fractures were more than twice as frequent in women with diabetes.

Among older men, distal radius fracture appears to be an early and sensitive marker of skeletal fragility [7]. More than any other fracture type, distal radius fractures correlate with a higher absolute risk for hip fracture in men (among women spinal compression fracture correlates more closely). A smaller study found shorter-than-expected life expectancy among patients with distal radius fractures when compared with peers of comparable age, sex, and comorbidities [8]. After sustaining this fracture, men were twice as likely to die as women with the same injury and did so almost twice as quickly. (See "Etiology of osteoporosis in men".)

Although older patients sustaining low-energy distal radius fractures represent an important population for osteoporosis screening and treatment, the opportunity is often missed. One Canadian study evaluated osteoporosis follow-up and treatment in a group of 156 patients who sustained a low-energy distal radius fracture [9]. They found that 32 percent of patients were receiving osteoporosis treatment before their injury, but after fracturing their radius only 21 percent more received osteoporosis screening, and only a few more began receiving a bisphosphonate or hormone replacement therapy. (See "Screening for osteoporosis in postmenopausal women and men".)

ANATOMY — The anatomy of the wrist is reviewed in detail separately. (See "Anatomy and basic biomechanics of the wrist".)

MECHANISM OF INJURY — The most common mechanism of distal radius fractures is Falling On an Out-Stretched Hand (sometimes abbreviated as FOOSH), with the wrist in extension. Minimal force is needed to produce a distal radius fracture in osteoporotic bone, and injury can occur after a fall from standing height or lower.

In healthy young patients, distal radius fractures often occur after violent injuries directly to the bone or by a compression load driving the scaphoid or lunate into the distal radius, producing a "die-punch" fracture [2]. Such high-energy fractures are more likely to be comminuted and intraarticular, and to occur in association with other significant injuries.

CLINICAL PRESENTATION AND PHYSICAL EXAMINATION — The patient with a distal radius fracture usually describes falling onto their outstretched hand or sustaining a blow to the wrist, and complains of wrist pain, and possibly deformity. In addition to standard inquiries about the mechanism of injury, the clinician should ask about any previous wrist injuries or surgery, and any resultant abnormal anatomy [10]. Also important are medical conditions affecting the injured extremity, such as carpal tunnel syndrome or conditions that can reduce the blood supply to the hand (eg, peripheral artery disease, scleroderma, thromboangiitis obliterans).

The clinician should inspect the injured extremity for swelling, deformity, and evidence of a possible open fracture. Swelling may or may not have developed by the time of presentation. Obvious deformities, such as the classic "dinner-fork" deformity (figure 1) associated with Colles' fractures, can occur, but the extremity may appear normal.

Examination includes an assessment of neurovascular status, including motor and sensory function of the median, radial, and ulnar nerves. Particular attention should be paid to sensation in the thumb and index fingers because acute median nerve compression is common, especially with severely displaced fractures. The clinician should assess circulation by palpating the radial pulse and testing capillary refill of the nail beds and fingertips. (See 'Indications for orthopedic consultation or referral' below.)

Range of motion of the wrist, including supination, pronation, flexion, and extension should be evaluated if possible. Ulnar deviation with palpation of the anatomic snuffbox is important to ascertain the presence of a scaphoid fracture. Clinical evaluation of a distal radioulnar joint (DRUJ) injury associated with a distal radius fracture is difficult. Ulnar-sided wrist pain and tenderness may be present due to a DRUJ or ulnar styloid injury.

In order not to miss associated injuries, the clinician should examine the involved extremity in its entirety, particularly the elbow and shoulder joints. A detailed description of the examination of the wrist and other joints is found elsewhere. (See "Scaphoid fractures" and "Evaluation of the adult with acute wrist pain" and "Evaluation of elbow pain in adults".)

DIAGNOSTIC IMAGING — When reading radiographs of distal radius fractures, clinicians should seek to answer four important questions:

Is there loss of normal anatomy (eg, fracture displacement or angulation, loss of radial height)? (See 'Anatomic landmarks and measurements' below.)

Is there involvement of the radiocarpal or distal radioulnar joint?

If joints are involved, is there discontinuity of the articular surface (ie, articular step-off) or diastasis (ie, separation) of the articular fragments?

Are high-risk features present (eg, severe comminution, articular step-off >2 mm, fracture-dislocation)? (See 'Indications for orthopedic consultation or referral' below.)

Anatomic landmarks and measurements — Accurate assessment of standard radiographs is essential for appropriate management [11,12]. Radiographic evaluation of the distal radius includes true posterior-anterior (PA) and true lateral projections (although the PA view is sometimes referred to in the medical literature as an “AP” [anterior-posterior], this is technically incorrect). Oblique radiographs often are included as a supplemental view [13]. Each view contains a small number of important landmarks and measurements for proper interpretation.

Posterior-anterior (PA) radiograph — Landmarks on the PA projection include the radial and ulnar styloids, the distal radioulnar joint (DRUJ), and the radiocarpal joint, including the proximal carpal bones. Important radiographic measurements include radial inclination, radial height, and ulnar variance.

Radial inclination (image 1 and figure 2) is the angle between one line drawn perpendicular to the long axis of the radius and a second line drawn between the distal tip of the radial styloid and the central reference point (CRP). The CRP lies midway between the palmar ulnar corner and the dorsal ulnar corner of the distal radius (image 2). The average angle is approximately 20 to 25 degrees, although there are slight sex differences (24.7 ± 2.5 for females; 22.5 ± 2.1 for males) [13]. The angle is often smaller with distal radius fractures.

Radial height (image 1 and figure 2) is the distance between two lines drawn perpendicular to the longitudinal axis of the radial shaft: one through the distal tip of the radial styloid and the second through the CRP. Normal height averages 11.6 ± 1.6 mm [13]. The measured height is often smaller with distal radius fractures.

Ulnar variance (image 1 and figure 2) is the distance between two lines drawn perpendicular to the longitudinal axis of the radial shaft: one through the distal articular surface of the ulnar head and the second through the CRP. Normally, the radial surface is distal to the ulnar surface by 1 to 2 mm (negative ulnar variance) [13]. When the ulnar surface is distal to the radial surface (positive ulnar variance), the biomechanics of the wrist can be impaired, especially if the distance is 5 mm greater than the contralateral wrist.

Lateral radiograph — In a true lateral projection (image 3), the radius and ulna should be superimposed, and the pisiform projected over the distal pole of the scaphoid. If the pisiform is found dorsal to the scaphoid, the patient is in relative pronation; if found palmar, the patient is in relative supination. Normally, the lunate is seated within the fossa of the distal radius, and the curvature of their articular surfaces should correspond. The central axis of the lunate should be collinear with the central axis of the radius. Palmar migration is a sign of radiocarpal instability [13].

The most important measurement on a lateral projection is palmar tilt (ie, volar tilt). AP distance may also be helpful.

Palmar tilt (image 3 and figure 3) is the angle formed by the intersection of one line perpendicular to the longitudinal axis of the radial shaft and a second line drawn through the apices of the palmar and the dorsal rims of the radius. The normal palmar tilt on a standard lateral projection averages 11.2 ± 4.6 degrees and does not differ between for males and females [13]. A smaller palmar tilt as a result of fracture is a risk factor for subsequent pain and disability.

AP distance (image 3 and figure 3) lies between the apices of the dorsal and palmar rims of the radius. Normally, AP distance should be slightly larger than the width of the lunate, and it averages 19.1 ± 1.7 mm. It is significantly larger in males (20.4 ± 1.1) versus females (17.8 ± 1.7) [13]. It can increase as a result of axial impaction injuries and suggests articular step-off.

Ultrasonography — Ultrasound can be a useful adjunct for the diagnosis of distal radius fractures [14,15]. Both the sensitivity and specificity of ultrasound in the diagnosis of distal radius fractures are reported to fall between 95 and 100 percent, while the positive and negative predictive values are reported to be 100 and 80 percent, respectively [14,16,17]. The most important ultrasonographic findings consistent with fracture are cortical disruption and adjacent joint effusion. Performance of the wrist ultrasound examination is discussed in detail separately. (See "Musculoskeletal ultrasound of the wrist".)

Classification — Although numerous classification systems exist for distal radius fractures, none is used universally. Distal radius fractures can be described using either a fragment-specific classification [13] or the standard Frykman classification. The Frykman classification system divides the fractures among four main groups based upon joint involvement. Within each major grouping, fractures with even numbers involve a concomitant ulnar styloid fracture. Frykman categories are:

Types I/II: Completely extraarticular; complications are uncommon once anatomic alignment has been achieved (image 4A-C)

Types III/IV: Extend into the radiocarpal joint (image 5A-B)

Types V/VI: Extend into the distal radioulnar joint (DRUJ) (image 6)

Types VII/VIII: Involve both radiocarpal and DRUJ articular surfaces and are highly unstable (image 7)

Two common eponyms associated with distal radius fractures are Colles and Smith. Colles' fractures involve dorsal displacement of the distal radius fragment (image 4A-C); Smith's fractures involve palmar displacement of the distal radius fragment.

Fracture dislocations — Two major types of radiocarpal fracture dislocations exist: Barton's and Hutchinson's.

Barton's fractures are separated into palmar and dorsal. They are best seen on lateral radiographs (image 8). Palmar Barton's fractures occur when the palmar radiocarpal ligaments avulse a radial fragment and displace the radiocarpal unit volarly. In a dorsal Barton's fracture, the dorsal radiocarpal ligaments avulse a radial fragment and displace the radiocarpal unit dorsally. In both types, the distal radius fragment maintains articulation with the carpus, accounting for the dislocation and instability. Closed reduction can be attempted, but these fractures are very unstable and reduction is usually lost. Barton's fractures generally require operative fixation [18,19].

A second type of fracture dislocation carries the eponym of Hutchinson's fracture, and it is also called the chauffeur's fracture (image 9). The typical mechanism is a direct blow to the radial styloid (such as might have occurred when the starting crank of an early automobile suddenly reversed with a backfire striking the chauffeur's wrist), or a fall back onto an outstretched hand held in ulnar deviation and supination. Such mechanisms cause the radioscaphocapitate ligament to avulse a large fragment of the radial styloid. This injury frequently results in concomitant lunate dislocation or scapholunate dissociation.

DIAGNOSIS — Definitive diagnosis of a distal radius fracture is made on the basis of diagnostic imaging studies, typically plain radiographs of the wrist. Radiographs are obtained when the diagnosis is suspected on the basis of a suggestive history, often involving a fall onto an outstretched hand, and examination findings, including pain, tenderness, and possibly deformity at the wrist.

DIFFERENTIAL DIAGNOSIS — The mechanism most often responsible for distal radius fractures, fall onto an outstretched hand, is associated with a number of other injuries that should be considered when evaluating patients with acute wrist pain from direct trauma. These injuries include fractures of the scaphoid and other carpal bones, injury to the distal radioulnar joint (DRUJ) or triangular fibrocartilage complex, and ligamentous injuries, which manifest differently depending upon the involved ligaments (eg, lunate or perilunate dislocation, scapholunate dissociation). Scaphoid injuries are common and often associated with tenderness in the anatomic snuffbox (picture 1).

Although clinical findings may vary somewhat depending upon the injury, there is substantial overlap in the presentations of many of the injuries listed here. Furthermore, two or more injuries may occur simultaneously as a result of the same trauma. Therefore, the only reliable method for distinguishing among injuries is diagnostic imaging, typically starting with plain radiographs of the wrist. The diagnostic approach to patients with acute wrist pain and the diagnosis and management of other major injuries that may be sustained by falling onto an outstretched wrist are discussed separately. (See "Scaphoid fractures" and "Overview of carpal fractures" and "Evaluation of the adult with acute wrist pain".)

INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL — Many distal radius fractures can be managed by knowledgeable primary care clinicians. Conditions requiring emergency referral to an orthopedic surgeon include the following:

Open fractures

Fractures associated with an acute neuropathy or compartment syndrome

Fractures associated with circulatory compromise in the hand (vascular surgical consultation may also be required in this circumstance)

In cases of neurologic or vascular compromise, immediate closed reduction of any displaced fracture should be performed, after providing analgesia, to attempt to alleviate symptoms. Persistent deficits despite reduction mandate emergency referral to an appropriate surgeon, or transfer if such care is unavailable.

Unstable fractures and those at high risk for complications should also be referred to an orthopedic surgeon [20]. The following conditions warrant orthopedic referral:

Palmarly displaced (eg, Smith's) fractures (see 'Classification' above)

Articular step-off greater than 2 mm

Large ulnar styloid fractures (ie, most or all of the styloid) with displaced fragments at the styloid base; these have an increased risk of distal radioulnar joint (DRUJ) instability [21,22]

Fracture dislocations (ie, Barton's or Hutchinson's) (see 'Fracture dislocations' above)

Distal radius fractures associated with scaphoid fractures or scapholunate ligament injuries [23,24] (radial styloid fractures are often associated with scapholunate injuries and such fractures are generally referred to an orthopedic surgeon)

Fractures with significant displacement or comminution; these are unstable and likely to lose position even if initial reduction is near-anatomic

Fractures likely to be unstable and unamenable to conservative treatment

The parameters for instability are poorly defined in the literature and vary with patient age and functional demands. Clinicians should be particularly concerned about patients who are physiologically young and have sustained high-energy, comminuted injuries. The presence of the following conditions on initial radiographs suggests fracture instability and the need for referral [25,26]:

Greater than 20 degrees of dorsal angulation

Fracture displacement in any direction greater than two-thirds the width of the radial shaft

Metaphyseal comminution with more than 5 mm of radial shortening (normal height = 10 to 13 mm)

Ulnar variance greater than 5 mm compared with the contralateral wrist (normal variance is 0 to -2 mm)

Intraarticular component (especially involving the DRUJ)

Advanced osteoporosis

Multiple scoring systems have been developed to predict instability in fractures of the distal radius [27-30]. However, these formulas have tended to underestimate fracture instability, and their use is not recommended. Instead, we suggest referral for any of the factors listed above.

INITIAL TREATMENT — Recognition of emergency conditions and the decision of whether to perform a fracture reduction are the most important steps in the acute management of distal radius fractures. If significant nerve injury (eg, paralysis, severe weakness) or vascular compromise is present, immediate reduction of the displaced fracture, with analgesia, is necessary to attempt to alleviate these symptoms. Persistent symptoms despite reduction mandate emergency consultation with the appropriate surgical specialist. Compartment syndrome is an emergency requiring immediate surgical release. (See 'Early complications' below.)

Should no emergent conditions exist, immediate reduction is not required, and appropriate treatment depends upon the type of fracture.

Nondisplaced extra-articular fractures (Frykman types I/II) — These fractures are relatively stable and can be treated with a well-molded sugar tong, reverse sugar tong, or double sugar tong splint [31]. (See "Basic techniques for splinting of musculoskeletal injuries", section on 'Sugar tong splints'.) The application of a circumferential cast in the acute setting increases the risk of distal ischemia and carpal tunnel syndrome, and it should not be performed [24].

Proper positioning within the splint has the elbow flexed to 90 degrees and the arm in neutral position (ie, without forearm supination or pronation, and without wrist flexion or extension). During the first several days following injury, the patient should elevate the arm, apply ice to the fracture frequently (while keeping the splint dry), begin active range of motion of the shoulder and fingers, and use analgesics as needed [3]. Opioids may be necessary; a short course of nonsteroidal anti-inflammatory drugs (NSAIDs) may also be used.

Displaced fractures (Frykman types I-VIII) — Displaced fractures with neurovascular compromise warrant an immediate attempt at closed reduction (see 'Early complications' below). Immediate closed reduction by an experienced clinician is appropriate, but not required, for displaced fractures without neurovascular compromise or radiographic evidence of instability [1]. (See 'Diagnostic imaging' above.) If a clinician capable of performing a reduction is unavailable, the provider may immobilize the fracture, provide appropriate analgesia, and discharge the patient, provided follow-up the next day for reduction by an orthopedist has been arranged.

Criteria for adequate reduction in a patient with high functional demands include (see 'Classification' above):

No dorsal tilt of the distal radial articular surface

Less than 5 mm of radial shortening

Less than 2 mm of displacement of fracture fragments

Substantial soft tissue swelling often accompanies displaced fractures, so splinting is recommended for postreduction immobilization (see "Basic techniques for splinting of musculoskeletal injuries", section on 'Sugar tong splints'). The application of a circumferential cast in the acute setting increases the risk of distal ischemia and carpal tunnel syndrome, and it should not be performed [24].

During the first several days following injury, the patient should elevate the arm, apply ice to the fracture frequently (while keeping the splint dry), begin active range of motion of the shoulder and fingers, and use analgesics as needed [3]. Opioids may be necessary; a short course of nonsteroidal antiinflammatory drugs (NSAIDs) may also be used.

FRACTURE REDUCTION BASICS — In cases of neurologic or vascular compromise, immediate closed reduction of any displaced fracture should be performed. Persistent deficits despite reduction mandate emergency referral to an appropriate surgeon, or transfer if such care is unavailable (see 'Indications for orthopedic consultation or referral' above).

Should no emergency conditions exist, immediate reduction is not required. Adequate anesthesia should be obtained prior to reduction.

Analgesia — Several methods can be used to provide effective analgesia prior to reduction of distal radius fractures. These include intravenous regional anesthesia (Bier block), peripheral nerve blocks, and hematoma (periosteal) blocks [32,33]. Hematoma blocks are effective and relatively simple to perform, but peripheral nerve blocks may provide superior analgesia. In a single-center randomized trial of 110 patients with displaced fractures of the distal radius, nerve blocks of the axillary or cubital nerve performed under ultrasound guidance provided significantly better analgesia compared with a hematoma block [32]. The performance of peripheral upper extremity nerve blocks is reviewed separately. (See "Upper extremity nerve blocks: Techniques".)

Performance of hematoma block — A hematoma block, with or without systemic opioids, provides adequate analgesia for reduction of most displaced distal radius fractures. Hematoma blocks are safe and easy to perform. Performance under ultrasound guidance may improve accuracy and effectiveness [15,34,35].

Skin and medication preparation – Don sterile gloves. Place the patients forearm on a clean, stable surface. Clean the skin over and around the fracture site with an antiseptic solution (eg, chlorhexidine). Maintain sterile technique throughout the procedure. Fill a 10 mL syringe with 5 to 8 mL of one percent lidocaine without epinephrine. Attach a 22-gauge needle to this syringe.

Palpation of fracture and insertion of needle – Gently palpate the dorsum of the wrist to locate the fracture step-off with one hand. Once the site is located, stabilize the forearm and insert the needle, also on the dorsal aspect of the wrist, and gradually advance it towards the fracture site.

Knowledge of the fracture pattern and displacement gained from review of the radiographs assists in determining optimal placement of the hematoma block.

Advancement of needle into fracture – Gradually advance the needle directly into the fracture site while continuously drawing back on the syringe. Aspirate continuously until a flashback of blood confirms placement of the needle tip in the fracture hematoma.

Injection of medication – Inject the mixture of blood and lidocaine directly into the fracture site. Some clinicians perform repeated aspirations and reinjections to disperse the anesthetic more completely before removing the needle.

Reduction techniques — Traction/counter-traction is critical to reduction. This can be achieved with or without finger traps (figure 4). The two approaches do not differ in the ultimate alignment attained or in the rate of failure to maintain reduction [36].

Regardless of the method used to reduce the fracture, finger traps (figure 4 and picture 2) are a useful adjunct before the procedure is attempted. Traction is applied by attaching the finger traps to the thumb, index, and middle fingers, while keeping the elbow flexed at 90 degrees and the forearm in neutral rotation. Five to 10 pounds (2 to 5 kg) of downward traction is placed on the distal humerus for at least five minutes before any reduction is attempted. This enables muscular relaxation and helps distract the fracture fragments, bringing the radius closer to normal length. It can be helpful to place a towel or sheet between the strap holding the weights and the brachium. This disperses the force of the weights hanging from the arm.

Active reduction can be performed with the patient still in the finger traps. For Colles' type fractures, the examiner's thumbs are placed on the dorsal aspect of the distal fracture fragment, while the fingers are placed on the palmar forearm just proximal to the fracture line. While applying downward axial traction to the proximal fragment, the distal fragment is pushed distally, palmarly, and ulnarly to eliminate the dorsal displacement and radial shortening.

A sugar tong, reverse-sugar tong, or double sugar tong splint is then applied and molded with the patient still in the finger traps [2]. (See "Basic techniques for splinting of musculoskeletal injuries", section on 'Sugar tong splints'.) A three-point contact molding technique is used to help hold the reduction [37]. For Colles' type fractures, ideal immobilization for the first two weeks consists of 15 degrees of palmar flexion, 10 to 15 degrees of ulnar deviation, and slight pronation [38].

Manual reduction can also be performed without finger traps, with the help of an assistant. The assistant provides counter-traction by holding the elbow. The clinician then supinates the patient's forearm with one hand while applying longitudinal traction to the distal fragment with the other hand and thumb. Next, the fracture is disimpacted by applying dorsal angulation (ie, accentuating the fracture pattern). Finally, the reduction is completed by pronating the forearm and wrist, followed by the application of some ulnar deviation, to correct the radial and dorsal angulation. The fracture is held in this position while a splint is applied and molded in the fashion described immediately above.

When only a single clinician is available to perform a closed fracture reduction, the closed unassisted reduction in emergency (CURE) technique may be used. In an observational study of 52 patients with a distal radius fracture, results using the CURE technique were comparable to standard closed reduction methods. The technique is described and video clips demonstrating the technique are provided in the attached reference [39].

FOLLOW-UP CARE — Treatment of distal radius fractures varies according to the patient's health, functional needs, and the injury sustained. Active patients with high functional needs require anatomic reductions, and they often need surgical fixation.

The most fundamental decision is whether to treat conservatively or surgically. Clinicians should consider such medical factors as bone quality, comorbidities, and functional demand. Fracture characteristics, associated injuries, risk of complications, and clinician experience with fracture management are also relevant. As an example, a 16-year-old skateboarder with a comminuted, displaced, intraarticular fracture requires surgical repair to achieve anatomic alignment; a sedentary 80-year-old with an identical injury needs immobilization and occupational rehabilitation (see 'Geriatric management' below). Finally, clinicians should inquire about patient preferences and social circumstances.

Conservative management with closed reduction and immobilization is appropriate for fractures that are reducible by closed manipulation and will remain stable thereafter [38]. A systematic review found insufficient evidence to determine which conservative treatments are most appropriate for common adult distal radius fractures [40]. Our recommendations below are based upon the limited literature assessing treatment of these fractures and our clinical experience.

Nondisplaced extra-articular (Frykman types I/II) — Patients are seen three to five days following injury to allow swelling to subside. The clinician should remove the splint, assess neurovascular status, and obtain radiographs of the arm out of the splint to confirm there is no loss of position.

If the fracture remains nondisplaced or minimally displaced, the clinician applies a short arm cast. The cast should extend from the distal palmar crease to within 5 cm of the antecubital fossa, with the wrist in neutral position. Patients should be seen in follow-up every two to three weeks thereafter until healing is complete. Radiographs are taken at the initial postcasting visit, at two weeks, and then sometime between four and six weeks after injury to confirm proper alignment [2].

The patient's wrist and forearm should remain immobilized until there is evidence of radiographic healing or the fracture site is nontender, generally four to six weeks postinjury. At this point, the patient can use a wrist brace in lieu of a cast. Complete healing usually requires six to eight weeks.

For patients over 60 years of age, the period of immobilization should be kept to a minimum to avoid post-immobilization stiffness. Early transition to a wrist splint may be helpful depending on fracture stability. In one randomized trial, patients treated with a wrist splint were more satisfied and regained function sooner than patients immobilized in a cast [41].

Evidence guiding the appropriate period of fracture immobilization in the geriatric population is lacking. Nevertheless, we think that older patients who meet the following criteria can be removed from their cast and placed in a wrist splint as early as two to three weeks following injury:

Extraarticular fracture of the distal radius

Minimal comminution present

Reduction was NOT necessary

Functional demands are few

Risk of fall or reinjury is low

Displaced (Frykman types I-VIII) — Once reduction is achieved, we suggest patients remain in the initial sugar tong splint for the following two to three weeks. The U-shaped part of the splint wraps around the elbow, thereby minimizing forearm rotation and maintaining the desired pronation or supination, according to the fracture type. The sugar tong splint also immobilizes the distal radioulnar joint (DRUJ), and splinted patients experience less pain than patients immobilized in a short arm cast [38].

Radiographs are taken in the sugar tong splint on the third, seventh, and twelfth days following reduction. This enables the clinician to detect quickly any loss of position and to assess the acceptability of any postreduction movement or residual deformity. During the first two weeks, the initial splint should be adapted and molded as soft tissue swelling decreases. This is achieved by wrapping the splint tighter with elastic bandages at each follow-up visit. Adequate tightness and molding throughout the early postreduction period reduces the risk of secondary displacement [38].

At two to three weeks, the splint is changed to a short arm cast. Wrist immobilization continues in the cast for another three to four weeks. The clinician must take care to maintain three point contact, and to avoid inadequate or excessively bulky padding [38]. At each visit, the clinician should assess fracture site tenderness, swelling, elbow and hand motion, and median nerve function. Radiographs should be obtained every two weeks and studied for signs of dorsal displacement, palmar angulation, and radial shortening [2].

Patients should be immobilized six to eight weeks, until there is evidence of radiographic healing and the fracture site is nontender. At this point, the clinician can remove the cast and place the patient in a wrist brace. Complete healing generally occurs within 8 to 12 weeks. The shortest possible period of immobilization is preferred for older patients; prolonged immobilization can cause joint stiffness and significant loss of function [2].

Once the cast is removed, patients should begin active range-of-motion exercises. Physical therapy may be needed to achieve acceptable motion, but most patients require only a single session of instruction [42]. Older patients and those with more complicated fractures requiring prolonged immobilization may require more extensive rehabilitation.

Styloid fractures — As described above, large ulnar styloid fractures (ie, most or all of the styloid is involved) with displaced fragments at the styloid base should be referred to an orthopedic or hand surgeon, as they are associated with an increased risk of distal radioulnar joint (DRUJ) instability [21,22,43,44]. Fractures of the tip of the ulnar styloid, distal to the DRUJ, are generally considered stable and can be managed conservatively. Radial styloid fractures are often associated with scapholunate injuries and such fractures are generally referred to an orthopedic or hand surgeon for possible surgical management. (See 'Indications for orthopedic consultation or referral' above.)

Isolated nondisplaced fractures of the ulnar styloid that do not involve the DRUJ and are not associated with DRUJ instability are uncommon, but can be managed conservatively in a short arm cast, as is done for nondisplaced radial fractures generally. (See 'Nondisplaced extra-articular (Frykman types I/II)' above.)

Geriatric management

Fracture management — Vigorous older adults with distal radius fractures should be referred for surgical treatment as indicated. These patients may do better with surgical repair [45]. However, many older patients, particularly those who are sedentary or have significant comorbidities (eg, diabetes, vascular disease), are best served by conservative nonsurgical fracture management and rehabilitation designed to maximize function, despite the presence of significant deformity. (See 'Indications for orthopedic consultation or referral' above.)

Osteoporosis complicates the management of many older patients with fractures. Optimal clinical results of distal radius fractures have been shown to correlate more closely with bone mineral density than with radiographic parameters [46]. Osteoporosis contributes to fracture instability. We suggest that patients with displaced fractures in osteoporotic bone be referred to an orthopedist with experience managing such injuries.

Regardless of management strategy, clinicians should minimize the length of time geriatric patients are immobilized because of the risk of joint stiffness and consequent disability. (See "Frozen shoulder (adhesive capsulitis)".)

Multiple studies support a conservative approach to the management of distal radius fractures in older adults [20]:

In a randomized trial of 304 patients 60 years or older with unstable fractures of the distal radius, 187 were randomly assigned to surgical repair using a volar plate, external fixation, or percutaneous pinning, while the remainder were immobilized in a cast [47]. While the rate of radiographic malunion was higher in the casting group, no clinically or statistically significant differences were noted in function or symptoms at 24 months among the treatment groups.

A study of patients older than 70 years of age who declined operative repair of their intra-articular distal radius fractures found 89 percent had a good or excellent functional outcome, despite 26 percent having only a fair or poor radiographic result [48].

Reduction may be of limited utility in older adults. A study of older patients with moderately displaced Colles' fractures randomized to reduction under Bier block and immobilization or to immobilization alone found no functional difference between the two groups [49]. On average, two-thirds of the dorsal angulation corrected by manipulation was lost by five weeks. The authors concluded that up to 30 degrees of dorsal angulation and 5 mm of radial shortening may be accepted in selected older patients.

These findings were confirmed in another study of 59 patients with a mean age of 82 years [50]. Of 60 fractures treated by closed reduction, 53 ultimately healed with significant deformity. Of 44 dorsally displaced fractures, reduction failed in seven cases initially, and 37 lost reduction during the following weeks of immobilization. The authors concluded that reduction of fractures of the distal radius is of minimal value in old and frail, dependent, or demented patients.

Osteoporosis evaluation — Fracture in an elderly individual warrants an evaluation for osteoporosis. A history of a fracture is an important risk factor for a subsequent fracture. Unfortunately, the majority of patients with vertebral, hip, and distal radius fractures do not receive evaluation and treatment for underlying osteoporosis. As a result, these patients frequently suffer additional fractures. Elderly patients with a history of fracture constitute a high-risk group that requires additional evaluation and treatment.

COMPLICATIONS

Early complications — Median nerve injury, compartment syndrome, and vascular compromise (although the last two rarely occur) are the most important early complications of distal radius fractures.

Acute carpal tunnel syndrome (ACTS) is found more frequently with severely comminuted or displaced fractures, patients treated with multiple reductions, and those splinted in extreme wrist flexion (>15 degrees) [51]. The clinician must perform a careful neurologic examination looking for signs of ACTS at the initial and first follow-up visits, and initial visits following any remanipulation. Weakness or loss of thumb or index finger flexion is the most important finding. Carpal tunnel release is indicated if symptoms progress, with or without reduction, or if surgical fixation is planned. Results are best if release is performed urgently [51-53]. (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis".) A mild sensory deficit consistent with median nerve contusion is often observed and generally is not caused by ACTS.

The interval from injury to development of compartment syndrome may range from 12 to 54 hours [54,55]. Increasing or constant severe pain and pain elicited by passive extension of the fingers are important findings, but measurement of elevated compartment pressures provides a definitive diagnosis. Emergent fasciotomy is required. A more detailed discussion is found elsewhere. (See 'Complications of closed reduction and cast treatment' below.)

Vascular injuries are rare in closed fractures, but injury to the radial or ulnar artery has been reported in high-energy injuries with significant fracture displacement. Perfusion often improves with reduction, but emergency vascular surgery evaluation is necessary for any persistent impairment [56].

Injuries to carpal bones and carpal ligaments occasionally accompany distal radius fractures, and they should be suspected in patients with persistent wrist pain despite acceptable alignment. A case series of 565 Colles' fractures revealed scaphoid fractures were initially missed in 0.7 percent of cases and intercarpal ligament injuries in 0.9 percent [57]. Scaphoid fractures in association with distal radius fractures should be treated with internal fixation [23]. Failure to identify and treat scapholunate ligament injuries with acute pinning has been shown to adversely affect outcome [24]. Fracture lines that involve the radial articular surface near the scapholunate ligament should raise suspicion of scapholunate ligament injury (image 10). If initial radiographs show normal scapholunate distance but suspicion is high, we suggest placing a thumb spica, in addition to appropriate wrist immobilization. (See "Scaphoid fractures".)

Complications of closed reduction and cast treatment — Skin tearing can occur with over-vigorous manual reduction and also with the use of older, metal finger traps. Skin rarely tears with the newer, cloth finger traps (picture 2). If metal skin traps are used, cloth tape can be placed over the fingers before they are hung to reduce skin injury [10].

Closed extremity fractures place patients at risk for compartment syndrome, although it is an uncommon complication of distal radius fractures [57,58]. Patients with compartment syndrome complain of increasing or constant severe pain and paresthesias. One potential warning sign may be increasing analgesic use. The clinician generally can palpate a firm, tense forearm, and can elicit pain by passive extension of the fingers, thereby stretching the flexor tendons within the forearm compartment. Measurement of elevated compartment pressures enables more accurate diagnosis. Normal pressure is less than 5 mmHg; pressure exceeding 30 mmHg generally warrants emergency fasciotomy. Alterations in capillary refill, distal pulses, and skin color are NOT reliable findings. Clinicians should warn patients about the symptoms of compartment syndrome and consider it in patients who complain of severe pain in the days immediately following fracture reduction.

Reports exist of compartment syndrome following closed reduction under local hematoma block [59], but it is a rare complication, and the role of the hematoma block has not been demonstrated [10]. Staphylococcus aureus osteomyelitis following hematoma block has also been reported [60]. Attention to sterile technique and to the amount of local anesthetic injected should minimize these complications.

Splinting the wrist in palmar flexion greater than 15 degrees increases the risk of ACTS [61] and complex regional pain syndrome [62]. Careful splinting that allows full flexion and extension of the metacarpal phalangeal (MCP) joints is important to prevent MCP joint contractures and proximal tendon adhesions [10].

Persistent sensory neuropathy following distal radius fracture can occur due to median nerve contusion at the time of injury or reduction, but it correlates closely with fracture malunion [63]. Surgical treatment with osteotomy [64] and/or release of the median nerve is indicated for persistent symptoms [65].

Tendon inflammation and rupture can occur with closed cast treatment. Rupture of the extensor pollicis longus (EPL) tendon is most common, with an incidence of 0.3 percent [66] to 3 percent [67,68], and it occurs between two weeks and 11 months (average seven weeks) after injury [67]. Diagnosis is usually made after rupture, and treatment is surgical. EPL rupture is more common with minimally displaced fractures. Tendonitis of the first dorsal compartment and of the extensor carpi ulnaris can also be seen after distal radius fracture. This is usually responsive to steroid injection, but it must be differentiated from triangular fibrocartilage tear or other ulnocarpal ligamentous injury [10].

Long-term outcomes/complications — A number of variables related to patient characteristics, fracture type, and radiographic findings predispose patients to the development of osteoarthritis and disability. Major complications are discussed below. The incidence of complex regional pain syndrome, another potential complication, may be reduced by prophylactic vitamin C, and is discussed elsewhere. (See "Complex regional pain syndrome in adults: Treatment, prognosis, and prevention", section on 'Prevention'.)

Osteoarthritis — Extraarticular fractures that are reduced to acceptable alignment rarely cause radiocarpal osteoarthritis. However, loss of radial height as a result of a distal radius fracture can cause a relative ulnar-positive variance (distal ulna extends beyond radius (image 1)), which increases the risk for ulnocarpal abutment and chronic wrist pain.

For fractures with intraarticular extension, there is a significant association between residual displacement of articular fragments at the time of bony union and the development of radiocarpal osteoarthritis [69]. In one case series, 100 percent of fractures with articular step-off of 2 mm or more developed radiographic evidence of osteoarthritis, compared with only 11 percent of those that healed with a congruous joint [70]. A second series found that a step-off of only 1 mm predisposed patients to radiocarpal osteoarthritis [71].

Residual disability — Long-term disability has been correlated with several radiographic parameters and fracture characteristics. Those associated with worse functional outcomes include radial shortening and dorsal angulation.

One series found a close correlation between the degree of postinjury radial shortening and disability: 4 percent of patients with normal height had poor function, whereas 25 percent of patients with 3 to 5 mm of radial shortening and 31 percent of patients with more than 5 mm of radial shortening had poor function [72]. (See 'Classification' above.)

In a review of 100 consecutive patients, dorsal angulation alone influenced early but not 10-year function [73]. However, several large case series have found that dorsal angulation of greater than 15 to 20 degrees, with or without radial shortening, led to compromised functional outcomes [74-76]. More than 10 degrees of dorsal tilt leads to a dorsal carpal shift with compressive forces, causing pain and insecurity with gripping, even during everyday activities [77]. Grip strength correlates inversely with the degree of osteoarthrosis [78]. (See 'Classification' above.)

Incongruency of the distal radioulnar joint (DRUJ) from residual dorsal angulation [79] or positive ulnar variance [80] has been associated with wrist pain. Triangular fibrocartilage complex (TFCC) tears occur not infrequently with distal radius fractures [81], and greater radial shortening and dorsal angulation is found in patients with TFCC tears (figure 5) [82]. A TFCC tear has occurred if the distal radius is shortened by more than 2.7 mm. TFCC tears are described separately. (See "Evaluation of the adult with subacute or chronic wrist pain", section on 'Triangular fibrocartilage complex injury'.)

The extent of fracture comminution and articular involvement correlates with loss of motion [77]. Range of motion loss after immobilization should be treated with aggressive physical therapy, unless it is caused by bony malalignment, in which case prolonged therapy is of no benefit [10].

Distal radius fractures frequently occur at work or under circumstances that allow for financial compensation. Injury compensation was shown in one study to be the best predictor of pain and disability at six months [83]. Another author found that patients with work-related injuries were more than four times less likely to return to work than those injured while away from work [71]. Patients receiving compensation for their injuries are likely to have poorer outcomes regardless of the anatomic result [10].

One important message to be gleaned from these data is that, with the exception of a subset of low-functioning geriatric patients, clinicians should aggressively seek to achieve congruent joint reduction and to prevent excessive loss of radial length or abnormal tilt of the radial articular surface.

Patient satisfaction — The factors most responsible for patient satisfaction remain unclear. Some claim patient satisfaction depends more on hand dominance and residual wrist pain than range of motion [84]. Others have found grip power [85] and return of wrist function [86] most significant. A study of operative patients found satisfaction correlated better with pain relief and grip strength than postoperative radiographic parameters [87].

RETURN TO SPORT OR WORK — Return to work is determined by the severity of injury and the tasks involved. Patients with sedentary jobs may return immediately; physical laborers may return to full duty only after they have regained near-normal wrist motion and strength. It is reasonable for participants in contact sports also to delay return to play until they have achieved near-normal motion and strength, and to wear a protective palmar splint during the first few weeks of play.

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

(See "General principles of fracture management: Bone healing and fracture description".)

(See "General principles of fracture management: Fracture patterns and description in children".)

(See "General principles of acute fracture management".)

(See "General principles of definitive fracture management".)

(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Fractures of the skull, face, and upper extremity in adults" and "Society guideline links: Acute pain management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: How to care for your cast (The Basics)" and "Patient education: Common wrist injuries (The Basics)")

Beyond the Basics topic (see "Patient education: Cast and splint care (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Epidemiology and mechanism – Distal radius fractures are common. Fractures in younger patients are the result of high-energy trauma, often during sports. Fractures in older patients are frequently the result of low-energy trauma to osteoporotic bone. The typical mechanism for distal radius fracture is a Fall Onto an Out-Stretched Hand (FOOSH). (See 'Epidemiology and risk factors' above and 'Mechanism of injury' above.)

Physical examination – Examination includes inspection for open fractures and deformity, assessment of wrist motion (if possible), and evaluation for associated injuries, such as scaphoid fracture or scapholunate ligament injury. The wrist may appear normal despite the presence of a fracture. In the days following injury or fracture manipulation, clinicians should pay close attention to neurovascular status (particularly median nerve function) and beware of acute compartment syndrome. (See 'Clinical presentation and physical examination' above.)

Diagnostic imaging – Diagnosis is typically made by radiograph. Clinicians should study the standard plain radiographs of the wrist, including postero-anterior (PA), lateral, and oblique views, looking for any loss of normal anatomy, the presence and degree of joint involvement (including both radiocarpal and distal radioulnar joints), and the presence of any high-risk features (eg, comminution, articular step-off >2 mm) (image 1 and image 3 and image 2). Abnormal measurements of radial inclination, radial height, palmar tilt, or ulnar variance suggest significant injury. (See 'Diagnostic imaging' above.)

Indications for emergency referral – Emergency orthopedic referral is required for the following conditions (see 'Indications for orthopedic consultation or referral' above):

Open fractures

Acute compression neuropathy or acute compartment syndrome

Vascular compromise despite reduction (emergent vascular surgery referral may also be required in this circumstance)

General indications for surgical referral – Unstable fractures and those at high risk for complications should be referred to an orthopedic surgeon. These include injuries with the following features: (see 'Indications for orthopedic consultation or referral' above):

Palmar displacement

Radial articular step-off greater than 2 mm, or involvement of the articular surface of the distal radial ulnar joint

Large ulnar styloid fractures with displaced fragments at the styloid base

Greater than 20 degrees of dorsal angulation

Displacement in any direction greater than two-thirds the width of the radial shaft

Metaphyseal comminution with more than 5 mm of radial shortening (normal height = 10 to 13 mm)

Ulnar variance greater than 5 mm compared with the contralateral wrist (normal variance is 0 to -2 mm)

Associated scaphoid fractures or scapholunate ligament injuries

Fracture-dislocations (see 'Fracture dislocations' above)

Advanced osteoporosis

Management of stable, uncomplicated fractures – Nondisplaced extraarticular fractures are relatively stable, and treatment is straightforward. Acute management includes the following interventions: (see 'Initial treatment' above):

Place the arm in a well-molded sugar tong, reverse sugar tong, or double sugar tong splint (NOT a circumferential cast), with the arm in neutral position (ie, without forearm supination or pronation, and without wrist flexion or extension). (See "Basic techniques for splinting of musculoskeletal injuries", section on 'Sugar tong splints'.)

Elevate the arm.

Apply ice to the fracture frequently (while keeping the splint dry).

Begin active range of motion of the shoulder and fingers.

Use analgesics as needed. Opioids may be necessary; a short course of nonsteroidal anti-inflammatory drugs (NSAIDs) may also be used.

Fracture reduction – Displaced fractures with neurovascular compromise warrant an immediate attempt at closed reduction. Immediate closed reduction by an experienced clinician is appropriate, but not required, for displaced fractures without neurovascular compromise or radiographic evidence of instability. (See 'Diagnostic imaging' above.)

If a clinician capable of performing a reduction is unavailable and there is no neurovascular compromise, the provider may immobilize the fracture, provide appropriate analgesia, and discharge the patient, provided follow-up the next day for reduction by an orthopedist has been arranged.

Our recommendations for postreduction care of displaced fractures do not differ from that of nondisplaced injuries described immediately above. (See 'Initial treatment' above.)

Criteria for adequate reduction in a patient with high functional demands include:

No dorsal tilt of the distal radial articular surface

Less than 5 mm of radial shortening

Less than 2 mm of displacement of fracture fragments

Splinting, casting, and follow-up – Splints and casts should not place the wrist in palmar flexion greater than 15 degrees, and they should allow full flexion and extension of the metacarpal phalangeal (MCP) joints to prevent complications.

A schedule for follow-up care, including timing of radiographs, is provided for both displaced and nondisplaced fractures. (See 'Follow-up care' above.)

Care of older adults – Vigorous older adult patients with distal radius fractures should be referred for surgical treatment as indicated. However, many older patients are best served by conservative fracture management (ie, without manipulation or fixation) and rehabilitation designed to maximize function, despite the presence of significant deformity. (See 'Geriatric management' above.)

Complications and prognosis – Complications from distal radius fractures fall into two main categories:

Early complications include acute carpal tunnel syndrome, vascular injury, and compartment syndrome. (See 'Early complications' above and 'Complications of closed reduction and cast treatment' above.)

Late complications include tendon irritation and rupture (especially of the extensor pollicis longus), osteoarthritis, wrist pain or instability, and loss of motion. (See 'Long-term outcomes/complications' above.)

Poor functional outcome correlates with abnormal anatomy. With the exception of a subset of low-functioning geriatric patients, clinicians should aggressively seek to achieve congruent joint reduction and to prevent excessive loss of radial length or abnormal tilt of the radial articular surface. (See 'Long-term outcomes/complications' above.)

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Topic 219 Version 39.0

References

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