Distal Radius Fractures

Treatment of a DRF depends on a solid understanding of the anatomy of the radius.

On the volar surface of the radius (see the image below), the lunate facet is to the left and the scaphoid facet to the right. The projection of bone just proximal and volar to the lunate facet is the lunate facet buttress. This is relevant because it is what supports the lunate facet, and it must be stabilized in volarly unstable fractures. The volar radial tuberosity is at the right margin of the bone, at the radial margin of the watershed line (see below). The surface is covered with the pronator quadratus (PQ). The cortical bone is quite thick and is strong, even in osteoporotic patients.

On the dorsal surface of the radius (see the image below), the Lister tubercle is seen in the center. This bone is a thin cortical shell, with little structural strength.

The radial surface of the radius is shown in the image below.

The ulnar surface of the radius, with the sigmoid notch for articulating with the ulna, is shown in the image below.

On the distal articular surface of the radius (see the image below), the scaphoid facet is to the right and the lunate facet to the left. This bone is the strongest of all the surfaces, and even if it is osteoporotic, it is quite strong.

A normal posteroanterior (PA) radiograph of the radius is shown in the image below. The ulna is generally within (plus or minus) 2 mm of the radius.

A normal lateral radiograph is shown in the image below. Note that the center of the lunate facet overlies the volar surface of the bone.

Several anatomic landmarks are important for the volar approach to the radius (see the image below).

The pathophysiology of a fracture is rather obvious: more load is imparted to the bone than the bone can sustain. Osteoporotic bone can break with very low impact. However, the patient should always be questioned regarding the circumstances of the injury, especially if he or she is older. Heart attacks or transient ischemic attacks (TIAs) can cause a DRF and should not be overlooked.

In addition, more problems may be involved with the injury besides the fracture itself. Although it is typical to think of the injury as involving only a broken bone, it is also worthwhile to consider that a DRF is a soft-tissue injury surrounding the broken bone; the immediacy of the radiographic diagnosis should not distract the surgeon from carefully assessing systemic issues or forearm soft-tissue issues.[5]

The standard DRF occurs in older patients, who have much weaker bones and can sustain a DRF from simply falling on an outstretched hand in a ground-level fall. An increasing awareness of osteoporosis has led to these injuries being termed fragility fractures, the implication being that a workup for osteoporosis should be a standard part of treatment. As the population lives longer, the frequency of this type of fracture will increase.

Younger patients have stronger bone, and thus, more energy is required to create a fracture in these individuals. Motorcycle accidents, falls from a height, and similar situations are causes of high-energy DRFs, and such fractures must considered to be a separate entity from the fractures in the older population. The injury to bone and soft tissue in high-energy DRFs is greater than that in typical DRFs. Trauma is the leading cause of death in the 15- to 24-year-old age group, and this is also reflected in the incidence of lesser traumas such as DRFs.

 

DRFs are among the most common types of fracture, and many authors state that they are the single most common type of fracture. DRFs have a bimodal distribution, with a peak in younger persons (18-25 years) and a second peak in older persons (>65 years). The mechanism of injury is unique to each group, with high-energy injuries being more common in the younger group and low-energy injuries being more common in the older group. This difference has implications for treatment.

Unresolved treatment controversies notwithstanding, most patients can resume their previous level of activity, including competitive sports. Most patients will likely lose a few degrees of final flexion and extension, and possibly supination as well; however, these limitations generally do not prevent full function.

Although many cases have been reported in which return to function was not limited by malunion or complications, patients are, in general, living longer and continuing to be active longer than in previous generations, and this places demands on the distal radius that were not seen previously. Consequently, even with apparently good care, some patients are unable to resume their prior level of functioning.

Nevertheless, all treatment approaches have a percentage of poor results, with decreased supination, prominent ulnar heads, ligamentous problems, distal radioulnar problems (usually instability), and degenerative joint disease being common. These are the cases that prompt researchers to continue to refine the techniques and devices.[6]

Patients, however, want more concrete prognostic statements. To this end, the following may be stated:

• Most patients treated with a volar fixed-angle plate can resume nonforceful ADLs within 3 days to 2 weeks
• Patients treated with a cast have the cast removed at 6 weeks and can then start ADLs
• Grip strengthening can often be started at 2 months after any type of treatment, but forceful use of the hand should be delayed for 3 months
• Contact sports or activities in which the likelihood of falling on an outstretched hand is high should be delayed for approximately 4 months

It should be kept in mind that these are just general guidelines and that great variation exists among specific cases and specific physicians.

The long-term prognosis for a properly treated DRF is good, even with an intra-articular fracture. If the articular surface is not comminuted and can be reconstructed, osteoarthritis is rare. Wrist range of motion (ROM) will continue to increase, and wrist tenderness with forceful use will continue to decrease even beyond 2 years.

In a patient with a distal radius fracture (DRF), the history should be directed toward ascertaining the probable amount of energy involved. A fall from 20 ft (~6 m) can be associated with a larger and more complex constellation of injuries (ie, beyond the distal fracture seen on the radiograph) than would be seen with a fall from a standing position. A history of prior fractures should be sought. A history of fragility fractures helps predict the stability of any reduction. A history of multiple high-energy fractures in a younger patient helps predict the patient's ability to comply with directions.

The median nerve is always compressed by a fall on the palmar aspect of the hand that results in a DRF, and the chart note should specifically document the quality (not just the presence or absence) of median nerve function. This should be clearly documented at the initial visit and then at each visit for the first several weeks or months.

Most therapies for DRF have implications for the median nerve. A cast or splint without a reduction may result in median nerve compromise due to pressure. A reduction, whether closed or open, involves some level of anesthesia, temporarily compromising the ability to assess the median nerve. Careful documentation of median nerve function at the first assessment is critical for planning and assessing treatment, not to mention protecting the surgeon from subsequent claims. DRFs are overrepresented in orthopedic malpractice suits.

The goals of any classification system are as follows:

• To stratify the injuries
• To guide treatment
• To facilitate discussion
• To predict outcome

Each classification system has its merits and weaknesses with respect to each goal, and often, more than one classification system is needed. (See the report How to Classify Distal Radial Fractures.)

The classification systems used most frequently for DRFs are the Frykman, Melone, AO (Arbeitsgemeinschaft für Osteosynthesefragen [Association for the Study of Osteosynthesis]), and Fernandez systems. Their key characteristics are as follows:

• The Frykman classification highlights the injury to the distal radioulnar joint (DRUJ)
• The Melone classification, based on the paper by Scheck, ^[7] highlights the fragmentation of the articular surface, especially the dorsoulnar corner of the distal radius
• The AO classification emphasizes the location as extra-articular, partial articular, or completely articular
• The Fernandez classification is based on the mechanism of injury, deduced from the displacement of the bone and the location of the fracture lines

A classification system that approaches the topic from another angle categorizes fracture patterns according to the three-column concept of the wrist and proposes treatment accordingly. This approach was independently developed by Medoff in 1994 (personal communication) and by Rikli and Rigazzoni.[8] The three columns are as follows:

• Lateral column (the radial half of the radius, including the radial styloid and the scaphoid facet, though Medoff differentiates these two)
• Central column (the ulnar half of the radius, including the lunate facet)
• Medial column (the ulna, the triangular fibrocartilage [TFC], and the DRUJ)

Each column is considered separately as to its need for reduction and stabilization. It should be noted that this conceptual approach does not exclude any other approaches; rather, it is complementary to them.

Plain radiographs (see the image below) are the foundation of treatment and are all that is needed for most distal radius fractures (DRFs). If the DRF is placed in traction as an early part of treatment, traction radiographs are very helpful. Often, the fragments cannot be adequately identified or assessed on the injury films; the traction views are often the first radiographs that define the fragments. Final reduction films must be evaluated for adequacy of reduction and for an assessment of stability, even though this is an area with no clear guidelines.

Computed tomography (CT) is considered by many to be useful for evaluating the articular fracture lines in an intra-articular fracture, particularly one that is comminuted, and it is sometimes helpful for planning the approach. A CT scan may be very helpful for determing optimal treatment in cases where the subchondral bone is comminuted. If the subchondral bone, particularly in the weightbearing areas of the scaphoid facet or the lunate facet, is highly comminuted, an approach that unloads the subchondral bone is warranted (eg, external fixation and bridge plating; see Treatment).

In the view of others, however, CT adds expense and delay but rarely changes the intraoperative game plan. Highly comminuted fractures that are only comminuted in the metaphysis or the distal shaft do not need a CT scan. Experience here is necessary, in that there are no clear guidelines or criteria for when to obtain a CT scan.

It should be kept in mind that whereas plain films underestimate the number of fracture lines, CT overestimates the number.

CT is necessary in planning intra-articular osteotomies for nascent malunions and mature malunions. Three-dimensional (3D) reconstructions may look impressive in presentations, but to date, they have not been very helpful in preoperative planning or postoperative assessment.

One study examined whether the locations of DRFs correlate with the areas of attachment of the wrist ligaments.[9]  Using data from CT scans of acute intra-articular DRFs, the study noted that articular DRFs were statistically more likely to occur at the intervals between the ligament attachments than at the ligament attachments. The most common fracture sites were the center of the sigmoid notch, the area between the short and long radiolunate ligaments, and the central and ulnar aspects of the scaphoid fossa dorsally.

These results suggest that CT may be used to identify the subsequent propagation of the fracture and the likely site of the impaction of the carpus on the distal radius articular surface.[9]  This is a very interesting approach that will likely become a standard part of understanding DRFs in the future, especially if the method can be refined.

The threshold for treatment, though not clearly defined, often involves assessing the degree of displacement (measured in millimeters). Both plain films and CT scans have been evaluated for their accuracy at the 1-mm level. Neither modality can reliably be read at this level, which adds to the challenge of treating DRFs.

Magnetic resonance imaging (MRI) is not indicated for evaluation of bony anatomy. Physical examination, the foundation of any  workup, is limited by pain and swelling in the acute phase, and the examination of wrist ligaments by physical examination is limited. An MRI can be considered in the setting of a high-energy injury (eg, a fall from a height or a motor vehicle accident) for the assessment of ligamentous injuries.

No consensus has been reached on classification systems, indications for surgery, or a particular choice of surgery (see below) for distal radius fractures (DRFs) since the orthopedic community first rejected Colles' contention in 1814 that all DRFs heal well. Gartland and Werley are generally credited with starting the revolution in 1951 with their paper examining more than 1000 DRFs, and Jupiter brought the discussion into the modern era with his 1986 paper in the Journal of Bone and Joint Surgery that emphasized the importance of reduction.

Despite the large number of papers published each year on DRFs, no consensus has been reached on treatment, and there is nothing in the literature to suggest that a consensus might be developing. Indeed, with one approach advocating immediate motion using a fixed-angle volar plate and another advocating immobilization for 3 months using an internal joint-spanning plate, treatment options seem to be diverging rather than converging.

One area of agreement is that DRFs in active adults should be reduced "anatomically." Unfortunately, however, no consensus has yet been reached on precisely what "anatomically" means in this context. That is, is a 0.5-mm displacement of an intra-articular fragment "anatomic"? What if it is extra-articular? Is the same definition of "anatomic" appropriate both for young, active patients and for older, inactive patients?

Indeed, there has been a trend toward deemphasizing anatomic results. Finsen et al. found that the anatomic factors explained only 11% of the variation in clinical outcomes in a series of 260 patients; the majority of the variation was due to variation among the patients themselves.[10]

Even with classification (see Classification), no consensus has been reached. The International Federation of Societies for Surgery of the Hand formed a working group of the most distinguished minds in DRF management to investigate for the existence of a consensus on the best classification system or, if one did not exist, to develop one. This working group concluded that no available system was universally useful or accepted and that the group could not develop a system that would be.

There is, however, a consensus that the goal of treatment is to restore the patient to the prior level of functioning. This is the starting point for all discussion.

Indications for reduction or operative treatment

Most authors advocate an anatomic reduction. This admonition, however, has two problems. First, not all patients need an anatomic reduction to be able to resume their normal activities. Second, the concept of anatomic reduction is not defined, as noted above. No authorities advocate operative reduction if the stepoff is 0.5 mm; however, a stepoff of 0.5 mm is obviously not anatomic. On the other hand, a 20° dorsal tilt is not anatomic, yet inactive elderly adults can easily return to their previous level of functioning with this alignment.

The indications for reduction or operative treatment are not based solely on age but must be tailored to the individual patient, with the key index to be based on activity level. It is also important, however, not to err in the opposite direction—that is, by concluding that any patient who is "old" does not require an anatomic reduction (one paper defined "old" as 50 years old!). Many patients are quite active and doing forceful activities with their hands and wrists, hiking, and biking well into their 80s, and a number of them even play tennis and golf.  Activity level is much more important than age: The goal generally is to return the patient to the prior level of activity. Balanced judgment is required.

Most authors would recommend anatomic reduction in a patient who is active in recreation (remembering that golf and tennis are common activities for persons older than 70 years) or engages in forceful activities at work or in recreation. Conversely, if the patient is sedentary, a lesser reduction may allow return to full activities. Usually, three parameters are relevant:

• Intra-articular stepoff - Most authors would accept less than 1 mm of intra-articular stepoff but not more than 2 mm; the 2020 American Academy of Orthopedic Surgeons (AAOS) evidence-based clinical practice guideline ^[11]  recommends surgery for nongeriatric patients (generally defined as those younger than 65 years) with a stepoff greater then 2 mm; however, the comments above about basing treatment on age should be kept in mind
• Dorsal tilt - Most authors, as well as the AAOS guideline, ^[11] would accept neutral dorsal tilt but not more than 10° in nongeriatric patients; the range of dorsal tilt that is acceptable is quite wide in the literature, with some authors not accepting anything more than neutral
• Radial length - Some publications suggest accepting 2 mm of radial shortening but not more than 5 mm; however, most surgeons would not accept more than 3-4 mm; the AAOS guideline ^[11] recommends surgery in nongeriatric patients with more than 3 mm of shortening

Radial tilt is generally considered a lesser parameter.

Defining anatomic reduction in terms of intra-articular stepoff is challenging. The main challenge lies in making a reliable determination of the relevant parameters—that is, how to distinguish between less than 1 mm and greater than 1 mm. (See Indications for Reduction in Distal Radial Fractures.) The difficulty is that opinions are based on studies using routine plain radiographs, which cannot accurately measure stepoffs with an accuracy of 1 mm.

The threshold of 1 mm for intra-articular displacement is commonly cited, referencing a 1986 landmark paper by Knirk and Jupiter.[12] However, Jupiter has repeatedly stated that this threshold is not the benchmark that subsequent authors have used, that the 1986 study had methodologic flaws, and that ligamentous injuries may account for functional limitations better than intra-articular stepoff does. Surgeons must review the literature with this in mind, because it changes the reliability of the conclusions reached by many authors after 1986.

Fewer comparative studies (either basic science or clinical) have been published on dorsal tilt, but this has not kept authors from making pronouncements. The range of anatomic alignment for dorsal tilt has reportedly been from 0° to 10°, with no proviso for less active patients. Given that a neutral (0°) alignment represents an 11° loss of volar angulation, even the most conservative figure is not truly anatomic.

Commonly, some older, inactive patients are able to achieve full resumption of their activities with dorsal tilts of 45° or more. Although orthopedic surgeons may find the radiographs of these patients disturbing and the clinical deformity not much better, some patients are quite satisfied and able to function in all of their activities of daily living (ADLs). This calls into question any rigid threshold of dorsal tilt, whether it be 0° or 10°. Most authors recommend no more than 0-10° of dorsal tilt in healthy, active individuals.

The basic science of radial length is clear. Shortening radial length by 2 mm doubles the load through the triangular fibrocartilage (TFC) and the ulna. The clinical relevance of this fact in the context of DRFs is unclear. Additionally, altering the radius length relative to the ulna affects the function and forces associated with the distal radioulnar joint (DRUJ). On the basis of less well-defined clinical grounds, most authors would not accept more than 3-4 mm of shortening.

For more detailed information on various studies and the parameters studied, see Indications for Reduction in Distal Radial Fractures.

Patient age considerations

The 2020 AAOS guideline[11] explicitly states that "Strong evidence suggests that operative treatment for geriatric patients (most commonly defined instudies as 65 years of age and older) does not lead to improved long term patient reported outcomes compared to non-operative treatment." This statement flies in the face of the experience of any surgeon who has treated high-activity patients older than 65 years and further demonstrates the inability of the Short Form (SF)-36 to assess differences in outcomes in DRFs in active, older adults.

This author has had to perform many osteotomies on distal radius malunions in patients older than 65 years who were significantly impaired by their malunion. If, as stated previously, the goal of management is to return the patient to his or her prior level of activity, then it follows that the decision whether to perform surgery must be based on that prior level of activity, not on an arbitrary age of 65 years. This is not to deny that patients who are rather inactive can be quite functional and happy with their malunion, even with 70º of dorsal tilt. Rather, it is to underscore the importance of treating in accordance with the patient's prior level of activity, goals, and wishes.

Stability of reduction

Another issue that has not been resolved is the stability of the reduction if it is performed in a closed procedure and without operative support to the fracture fragments. Some authors believe that a 30º dorsal tilt or any radial shortening will not be stable and will subside; others feel that 20º is the correct threshold for intervention. If function requires that reduction be achieved and maintained, surgery is needed to maintain it.

It is now generally agreed that weekly radiographic assessment is required for approximately 3 weeks for displaced fractures that have been reduced. Fractures do not commonly subside after 3 weeks, but this is not a certainty. Radiographs after 3 weeks are indicated for fractures that have subsided in the first 3 weeks or that appear to be quite unstable. Care must be taken to compare the current radiograph with the first postreduction radiograph because subsidence is gradual and can be difficult to detect between any two consecutive films. If subsidence is detected later in the course of healing, the situation becomes a nascent malunion rather than a DRF, and managment is much more difficult.

Some articles in the literature have challenged the need for postoperative radiographs and even the need for radiographs after closed reduction.[13]  However, those authors who do recommend follow-up radiographs assign greater importance to catching those instances of subsidence than to the cost of postoperative radiography. Subsidence is not rare, and as noted above, DRFs are overrepresented in orthopedic malpractice suits, especially in cases involving late discovery of subsidence.

Choice of treatment approach

Management of DRFs has always been an area of intense research and innovation. It changed more rapidly in the decade after 2001 than in any comparable previous period and has now stabilized somewhat. Whereas percutaneous pinning and external fixation remain the mainstays of treatment throughout much of the world, with strong and somewhat idiosyncratic national trends attributable to the prominence of individual surgeons in those countries, volar fixed-angle plating has become popular and has dramatically shifted the landscape in several ways.[14, 15] Bridge plating has replaced external fixation in many trauma centers.

For many surgeons, the volar approach using fixed-angle devices designed for subchondral support (in distinction to the bicortical approach of diaphyseal plating) is the main treatment option for dorsally unstable DRFs. Orbay popularized this treatment and broadened its applicability to highly comminuted intra-articular fractures with the extended flexor carpi radialis (FCR) approach, pronating the radial shaft out of the way and looking directly at the undersurface of the articular bone.

The low rates of complications and postoperative pain, the quality of the results, and the rapid return to activities have, for some surgeons, shifted the risk-to-benefit balance in such a manner that they are offering patients the option of surgery versus a cast for stable undisplaced or stable reducible fractures.[16, 17] (See Radius Fracture with Immediate Return to Work.)

The complication rate for volar fixed-angle plates has not yet been clearly defined. Most cases of tendon injury or rupture are due to failure to follow proper technique. One important aspect of technique is to avoid any past-pointing of distal screws and, preferably, to place their tips 2-4 mm short of the dorsal cortex. A second is to use a plate that does not extend distally as far as the volar wrist capsule. Another landmark commonly used is the watershed line of Orbay (see the image below); plates should not extend proximal to or volar to this line.

The issue of plate prominence has been thoroughly reviewed in the literature. Soong et al studied the relation of the plate to the volar rim of the radius.[18] Plates that do not extend volar to the critical line, defined as a line tangent to the volar rim of the lunate facet, are classified as grade 0; those volar to the line but proximal to the volar rim are classified as grade 1; and plates directly on or distal to the volar rim are classified as grade 2.

In a group of patients where grade 2 volar prominence was present, the increased incidence of flexor tendon ruptures approached statistical significance.[18] The authors therefore suggested that plate placement volar to the critical line and distal to the volar rim could increase the risk of flexor tendon rupture. It has been the general experience of hand surgeons that tendon ruptures occur most commonly in grade 2 placements, and this should be avoided. A summary would be that plates should be proximal to the watershed line of Orbay and dorsal to the critical line of Soong.

Finally, many surgeons feel that the tendons are better protected if the plate is completely and securely covered with the pronator quadratus (PQ). This was initially debated after the introduction of volar plating in 2000 by Orbay, but there is now a broad consensus that the plate should be covered. Orbay and Nelson have taught an approach known as the PQ technique, in which the PQ is released with a rim of fibrous tissue cut from its origin along the lateral septum and the proximal aspect of the volar wrist capsule. The rim of fibrous tissue along the radial and distal aspects of the PQ that is left by this technique allows more secure replacement of the muscle at the end of the procedure.

Arthroscopy continues to be a controversial adjunct to the management of intra-articular fractures. Whereas the rate of unrecognized scapholunate, lunotriquetral, and TFC tears in DRF has been shown to be greater than 60%, there continues to be disagreement about the role of arthroscopy because of the lack of any outcome studies that have demonstrated improved results.

Yamazaki et al compared radiographic and functional outcomes on the basis of the use of either fluoroscopy or arthroscopy to aid the articular reduction.[19] There were no significant differences in wrist range of motion (ROM); grip strength; and Disabilities of the Arm, Shoulder, and Hand (DASH) scores by 48 weeks after surgery. The average articular gap and stepoff were 0.9 and 0.7 mm, respectively, in the fluoroscopy group and 0.6 and 0.4 mm, respectively, in the arthroscopy cohort.

The decision to use arthroscopy in the treatment of DRFs should be based on the surgeon's facility with dry arthroscopy and the displacement of intra-articular fragments. Most surgeons feel that the reduction can be done successfully by using the proximal surface of the proximal row as a template.

Whichever approach is used, it is important to study the injury film to determine the "personality" of the fracture. Traction views are immensely helpful, in that they partially realign the fracture fragments and allow a better understanding of the fracture.

In addition, recognition of different patient expectations must be incorporated into the decision-making process at an early stage. An elderly person who is active in self-care but is not active outside the home will not have the same set of expectations as a patient who may seem elderly to the treating surgeon but remains an active tennis player at 75 years of age. Published papers that define "elderly" as meaning older than 50 years seem ridiculous to surgeons who are operating well past the age of 65 years; such papers tend to be written by residents in their 20s.

In the treatment of DRFs, the goal is to return the patient to his or her prior level of functioning. The physician's role is to discuss the options with the patient, and the patient's role is to choose the option that best serves his or her needs and wishes. This treatment paradigm can be illustrated by a case discussion of an approach to the surgical treatment of stable fractures that are in acceptable alignment (see Radius Fracture with Immediate Return to Work).

Many DRFs can be treated nonoperatively.[20, 21] Those that are undisplaced or minimally displaced (the definition of minimally displaced is controversial and varies with age and activity level) can be treated in a cast for 6 weeks. In most instances, unless the distal ulna is fractured and unstable (type I and II ulna fractures are usually stable), it can be treated in a short arm cast. Long arm casts are not required if the ulna is stable; additionally, these casts significantly disable the patient during the treatment of the fracture.[22]

Some fractures in elderly persons that are compressed dorsally can be minimally painful and can appear to be clinically stable. These fractures may be treated with a splint only. This variant is somewhat rare.

Low-activity elderly patients can have very high function and return to prior activities even with a significantly displaced fracture. A 45° dorsal tilt can be highly functional in a patient who does not drive and is not active outside the home. Clinically, such patients have an unsightly wrist (with a prominent ulnar head) that has limited supination and flexion, but they do not have symptoms with ADLs. Success in these cases strongly depends on the patient, not the surgeon, making the treatment choice.

A systematic review concluded that in patients with DRFs who are aged 60 years or older, cast immobilization provided functional outcomes similar to those achieved with surgical treatments (volar locking plate system, nonbridging external fixation, bridging external fixation, or percutaneous Kirschner wire [K-wire] fixation).[23] Cast immobilization had the worst radiographic outcome yet the lowest complication rate. Additional studies are needed to evaluate the recovery rates, costs, and outcomes of these treatment methods.

In 2009, the American Academy of Orthopaedic Surgeons (AAOS) issued a clinical guideline on the treatment of DRFs.[24] Many of the recommendations in the guideline lacked strong supporting evidence and were considered inconclusive. However, the following recommendations were supported by moderately strong evidence:

• Rigid immobilization is suggested in preference to removable splints in nonoperative treatment for the management of displaced DRFs
• For all patients with DRFs, a postreduction true lateral radiograph of the carpus is suggested for assessment of DRUJ alignment
• Operative fixation is suggested in preference to cast fixation for fractures with postreduction radial shortening greater than 3 mm, dorsal tilt greater than 10º, or intra-articular displacement or stepoff greater than 2 mm
• Patients probably do not need to begin early wrist motion routinely after stable fracture fixation
• Adjuvant treatment of DRFs with vitamin C is suggested for the prevention of disproportionate pain

On the basis of the available evidence, the AAOS was unable to make a recommendation for or against casting as definitive treatment after initial adequate reduction or to recommend any specific surgical method over another.[24]

An updated guideline was issued in December 2020 by the AAOS and the American Society for Surgery of the Hand (ASSH).[11]

Traditionally, surgical treatment has been reserved for displaced, irreducible DRFs or reducible but unstable DRFs.[25] One approach that is becoming more popular is to provide surgical treatment to patients who cannot or do not want to accept the constraints of cast treatment because of ADL, work, or recreational concerns.

No consensus has been reached as to which surgical treatment is best. Several options are available, each with its own variations.

Closed reduction and percutaneous pinning

Closed reduction and percutaneous pinning had been popular for many years but has fallen out of favor in the United States. It continues to be one of the most popular techniques internationally, in part because of its low cost, use of simple and widely available materials, and effectiveness. The pinning can be of several varieties, including the following:

• Clancey pinning (ie, 0.062-in. wires into the radial styloid and the dorsal ulnar corner of the radius, crossing the fracture site; see the images below)
• Kapandji pinning (ie, wires or arum pins placed into the fracture site dorsally and used as levers to reduce the fracture and then to stabilize it) ^[26]

The two main limitations of closed reduction and percutaneous pinning are pin-tract infection and loss of reduction. This technique is not as well tolerated by patients as volar plating is.

External fixation

External fixation (see the image below) became the most popular treatment throughout much of the world in the decades after the development of a radius-specific fixator by Anderson in 1944. The proper application technique, however, was not defined until 1990 by Seitz. Small open incisions are used to avoid injuring the sensory branches of the radial nerve and to ensure central placement in the second metacarpal and the radial shaft. This technique continues to be one of the most popular approaches internationally.[27, 26]

Many variations of external fixation have been developed. One variation of the fixator allowed early motion with the fixator still in place. The concept was originated by Clyburn and popularized internationally by Pennig. The axis of motion of the fixator was placed over the center of motion of the wrist, thought to reside in the center of the head of the capitate.

This approach has largely been abandoned because of theoretical criticisms and clinical experience. The theoretical criticisms are related to the location of the rotation—that is, whether it is an instant center or a constant center and whether it is possible to place the center of motion of the fixator reliably over the center of motion of the wrist. An additional practical consideration is the impossibility of having a center of motion of the fixator not coaxial with the center of the wrist.

Clinical studies also noted a decrease in final ROM and an increase in complications related to the device; thus, early motion in external fixation has largely been abandoned. Nevertheless, some researchers are still investigating this technique, and it is still used clinically in some regions of the world.

In a study of patients with DRFs that compared complication rates after external fixation and after volar plating, the volar-plate group experienced more tendon and median nerve complications; however, the external fixation group had a significantly higher overall complication rate.[28] Whereas there were no significant differences between the groups in the scapholunate angle or palmar tilt measurements, the volar plate group had significantly better arc of motion in pronation-supination and flexion-extension and better grip strength.

The author is a proponent of external fixators; however, it should be noted that at this time, most surgeons would place a volar plate rather than an external fixator when doing so is feasible. The rate of complications after volar plating (tendon irritation, tendon rupture, loss of fixation, inadequate fixation, or plate removal) has dramatically decreased.

Some studies have shown that open reduction and internal fixation (ORIF) resulted in better grip strength and ROM than closed reduction and bridging external fixation in the treatment of nonreducible DRFs. The results from one study noted that these benefits diminished with time; after a mean of 5 years, both groups had approached normal values.[29]

Dorsal plating

Dorsal plating (see the images below) had its greatest popularity in the 1990s, with the development of plates specifically for the distal radius. Because of tendon irritation problems, this technique has lost most of its appeal for most fractures.

Fragment-specific fixation

Fragment-specific fixation was originated by Fernandez, who called it the limited open approach, and was developed and popularized by Medoff, who studied with Fernandez and coined the term fragment-specific fixation. This approach uses very small low-profile plates, such as those developed by Medoff (see the images below). Many companies followed Medoff's lead, and many systems are now available that are specifically designed for the radial column, the central column, or the ulnar column of the radius.

Fragment-specific fixation lends itself to many types of fractures and has been used by many academic medical centers. However, it is challenging to learn, and often the plates must be removed.

Nonspanning external fixation

Nonspanning external fixation (see the image below) was popularized by McQueen and capitalized on the strength of the subchondral bone and the volar cortex. Although the proponents of this procedure touted the possibility of early motion, others found that ROM was poor. It has not seen wide acceptance after several years of experimentation by numerous surgeons.

Volar plating

Volar plating (see the images below), especially for dorsally unstable fractures, was independently developed by three different surgeons: Orbay, Jennings, and Drobetz. It was Orbay, however, who successfully developed a practical device, promoted it internationally, and was the first to publish information on it[16, 17] ; thus, he is properly considered the grandfather of the technique.

Volar plating is the most popular approach in much of the developed world, but it is more costly than techniques such as closed reduction or percutaneous pinning. Many locally designed and locally manufactured volar plates, often exact copies of the Orbay design, are available at lower prices than the Orbay design and its descendants.  

Complications of volar plating, particularly the incidence of tendon rupture, are now becoming recognized.[14, 26, 30, 31, 32, 33] Initially, such complications were thought to be rare, but the widespread adoption of this technique without adherence to some of the finer points, coupled with the use of imitation plates that lacked some of the original design features, led to increases in the rate of complications.

As noted earlier (see above), a study of external fixation versus volar plating of DRFs found that the latter led to more tendon and median nerve complications but the former to a significantly higher overall complication rate.[28] At present, most surgeons would place a volar plate rather than an external fixator when plating is feasible (the author is a proponent of external fixators).

The results from another study noted that extra-articular and simple intra-articular DRFs realized similar outcomes in motion, grip strength, Gartland and Werley scores, and DASH scores at 2 years when treated with ORIF with a volar locking plate.[34]

In a 2014 meta-analysis of six trials that included 445 patients with unstable DRFs, Li-Hai et al determined that whereas external fixation had a lower rate of reoperation due to complications, volar locking plating yielded better functional recovery in the early postoperative period.[35] However, the two methods resulted in comparable functional recovery at 1 year after the procedure.

Spanning internal fixation plates

Spanning internal fixation plates were originated by Becton and popularized by Ruch,[36] and several companies make such plates. The screws are placed into the metacarpals and the midradial shaft, and the plates are removed at 3 months. This technique is usually reserved for the following two situations:

• Multiple trauma where circumstances do not allow the anesthesia time (1-2 hours) required for volar plates
• Highly comminuted fractures that cannot be adequately supported by the volar subchondral approach

Surgical techniques internationally

Despite the many techniques and the large number of studies on DRFs, no consensus has been reached on the best surgical approach. Strong regional tendencies exist, such as volar plating in the United States, Kapandji pinning in France, and traditional external fixation in the United Kingdom, in Italy, and in India. In some regions (eg, Japan and Germany), the plates are typically removed; however, in others (eg, the United States), they are rarely removed.

Percutaneous pinning

Clancey technique

After adequate anesthesia is established, prepare the skin. Many surgeons find that placing the fingers in finger-trap traction assists with reduction.

Reduce the fracture, and place a 0.062-in. K-wire into the radial styloid. Using image intensification, drive the K-wire across the fracture site and into (but not through) the opposite cortex. Pin migration can be limited by not going through the opposite cortex, but the pin must be securely in the cortex to maintain the reduction. Place the second pin into the dorsal ulnar corner of the radius. Under image intensification, drive the pin across the fracture site and into the opposite cortex. Additional pins can be placed if needed for stability.

Kapandji technique

Prepare as above, but place the pins into the fracture site dorsally. Lever the distal fragment into place with the pin, observing the reduction with image intensification, and then drive it into the volar cortex. Usually, more than one pin is used. Kapandji has developed special pins for this purpose, known as arum pins (because of their resemblance to the arum lily flower).

Volar plating

Make a skin incision directly over the FCR tendon; the incision should be approximately 10 cm long and need not cross the wrist crease.

Mobilize the FCR tendon radially, and incise the floor of the FCR tendon sheath. Distally, be aware that the course of the branch from the radial artery to the superficial palmar arch is variable and can cross the FCR tendon. Divide the septum between the FCR tendon and the flexor pollicis longus (FPL) tendon distal to the wrist crease. This avoids making a skin incision distal to the wrist crease. If, subsequently, the distal portion of the surgical field cannot be visualized adequately, release this septum further.

Release the muscular fibers of the FPL, originating from the shaft of the ulna or the septum between the radius and the first dorsal compartment. The PQ is seen, often with a tear in its fascia where the shaft has displaced and torn it at the moment of fracture.

Release the PQ 1-2 mm distal to the line marked by the distal end of the muscular fibers and the proximal end of the fibrous tissue that continues distally to become the wrist joint capsule (the so-called PQ line). Release the PQ radially 1-2 mm beyond the radial margin of the muscular fibers of the PQ by including a small margin of fibrous tissue from the septum of the first dorsal compartment. The fibrous rim, distally and radially, allows a secure repair of the PQ and protects the tendons from the plate.

Reflect the PQ, and release the brachioradialis (BR). Clear the fat from the volar wrist capsule.

One of the following two approaches is then taken:

• Reduce the fracture, and place the plate
• Alternatively, partially reduce the fracture, place the distal row(s) of screws, and use the plate to obtain the final few degrees of volar tilt

If unreduced intra-articular comminution is noted, a different approach is required. Release the BR, if it was not released previously. Release the first dorsal compartment from the radius, and pronate the radius shaft away from the articular fragments. Using the carpus as a template, reduce the intra-articular fragments, perform pinning or bone grafting (or both) as necessary, and then supinate the radial shaft and continue as above.

Document the reduction using the facet lateral view and the facet posteroanterior (PA) view with the mini C-arm and with fluoroscopic views in the facet manner, aligning the view with the joint surface, not the clinical position of the forearm.

Be careful to assess the position of the tip of each distal screw. The radial styloid screw may be either in the joint or outside the radial cortex radially, and facet or oblique views must be obtained to evaluate this possibility (standard PA and lateral views will not suffice for this purpose). The distal screws should not extend beyond the dorsal cortex; indeed, they probably should be 2 mm short of the dorsal cortex. The dorsal cortex is very thin and usually comminuted; therefore, it provides no increase in fixation security. Carefully check for past-pointing; as little as 1 mm of past-pointing can shred a dorsal tendon if it is precisely in the wrong place.

Close the PQ securely with interrupted sutures, making sure to close soft tissue over the distal edge of the plate. The shaft need not be covered, because the tendons are not in contact with the shaft. No intermediate closure is needed. Close the skin.

External fixation

The key to external fixation is placing the pins through small open incisions. Blind percutaneous placement or placement through small stab incisions increases the rate of nerve and tendon injury and makes it easier to create open section defects and off-center placements into the bones.

Proximally, the plane of dissection should be dorsolateral, not directly lateral, through the extensor carpi radialis longus (ECRL) and the extensor carpi radialis brevis (ECRB) or through the ECRB and the extensor digitorum communis (EDC). This approach avoids placing the pins near the radial sensory nerve and minimizes the risk of injuring it upon pin insertion or removal or subjecting it to the minor cellulitis of the pin tract.

Probably the greatest change in the management of DRFs since 2010 has come in the area of perioperative pain management. The primary stimulus for this monumental change has been the opioid epidemic in the United States,[37]  but there have been indications that this may be becoming a problem globally[38]  in Europe and in economies where either lower cost or easier access allow wider use of opioids. Another influence may be that in many countries, postoperative pain generally is not considered to require opioids. In any case, the trend is certainly to decrease the use of opioids in favor of a true multimodal program (see below).

The term perioperative is intentionally used here instead of postoperative because it has become clear that successful postoperative pain management must start preoperatively. If pain management is started after surgery, it is too late.[39]

Many modalities are available for management of pain related to surgery. However, some are not relevant to DRF surgery, including intravenous (IV), intramuscular (IM) or subcutaneous (SC) opioids; patient-controlled anesthesia (PCA); regional blocks; indwelling catheters; and gabapentin.[40]  Quite successful pain management in this setting has been achieved with simple over-the-counter medications, as documented in several prospective studies[41]  and by the author.[42]

Medication is not the only means of managing perioperative pain and, indeed, may not be the best therapy.[43]  For decades, the International Association for the Study of Pain (IASP) has advocated a multimodal approach,[44]  which the author and many other surgeons have shown to be effective for many surgical procedures.[45]  The multimodal approach can include any of the following[42] :

• Preoperative counseling (often a combination of face-to-face, handout, and online material)
• Preoperative acetaminophen arthritis pain (650 mg, 8-hr sustained release) plus naproxen sodium just prior to surgery
• Preincision blocks with short-acting medications such as lidocaine with epinephrine
• Postsurgery blocks (applied prior to wound closure) with long-acting medications such as 0.5% bupuvicaine with epinephrine
• Postoperative acetaminophen arthritis pain (650 mg, 8-hr sustained release) plus naproxen sodium twice daily for several days
• Elevation
• Cold therapy
• Psychological support (eg, hand therapist, physician telephone call, written material, online material)

Opioids can certainly be part of a multimodal approach, but the need for opioids has been found to be vastly less than was once thought.[46] The multimodal approach has reduced opioid use after DRF surgery, with one study finding that 72% of patients elected not to take any opioids because of a lack of postoperative pain with the multimodal approach only.[42] It is the author's experience that when a tailored multimodal approach is used, only the rare DRF patient will require opioids. The need for opioids is determined more by patient characteristics than by surgical procedure.

Surgeons may want to consider the use of nonopioid or minimal-opioid methods as part of a multimodal perioperative pain strategy; such methods have been found to be successful not only in relieving pain but also in avoiding constipation and overuse or diversion of opioids.[41]

Postoperative management varies, with little evidence in support of the different options. Some surgeons who treat a DRF with dorsal or volar plates or with an external fixator do not use any splint or cast. This approach usually requires good postoperative pain management. In such cases, ROM therapy can be started as soon as 3 days after surgery. Some surgeons routinely use a splint or, rarely, a cast, feeling that patients need the support to prevent pain.

There is no consensus on how long postoperative support should be maintained, but most surgeons probably use it for 2-4 weeks. Most external fixators are kept in place for 6 weeks, but 8 weeks is also common; and some fractures that are not bone-grafted still collapse at 3 months. Spanning plates are typically removed at 3 months. The ultimate ROM in patients with spanning plates left on for 3 months does not differ from that in patients who have a volar plate and start motion 3 days after surgery. This finding calls into question the traditional AO recommendation of rigid internal fixation and immediate postoperative mobilization, which was taught for decades.

It is important that volar plates be evaluated via facet views, not standard posteroanterior (PA) and lateral views. This point seems obvious intraoperatively, but most surgeons forget it in the clinic, where routine PA and lateral views are obtained. Radiology technicians must be instructed to take facet views in the clinic for patients who are treated with volar plates. For both the PA facet view and the lateral facet view, the right amount of tilt can be achieved by placing a roll of cast padding under the wrist.

It is advantageous to discuss postoperative hand therapy with the patient and to arrange the appropriate appointments before surgical treatment; this includes obtaining the required authorization. Otherwise, the full benefits of the procedure may be lost because of paperwork issues.

Most surgeons keep casts on for 6 weeks, but some compressed fractures require only a splint. Volar fixed-angle plates require no splinting, and ROM can start at 3 days. Spanning internal fixation plates are usually removed at 3 months, and therapy is initiated at that time. It is difficult to make useful generalizations.

The use of postoperative or post–cast treatment physical therapy is controversial and seems to be related more to surgeons' training and preferences than to evidence from scientific studies. Valdes et al prospectively enrolled 50 DRF patients and randomly assigned them to two treatment groups (therapist-supervised hand therapy and home therapy with therapist instruction)[47] ; at 3 and 6 months, there were no significant differences between the groups.

It might be prudent to allow self-actualizing patients to do their own therapy, with some guidance provided by a therapist or via a handout from the surgeon, and to reserve therapist-supervised hand therapy for patients who need encouragement and support, who develop finger stiffness, or who have sustained greater soft-tissue and bony injury.

As a rule, DRFs heal quickly. Nonunion is usually not an issue; the most common problem is malunion before or after treatment is initiated. Careful attention to follow-up radiographs helps avoid this problem. Each type of operative treatment has its own complications.[48, 49, 50, 51]

Percutaneous pinning

Percutaneous pinning has the following two principal areas of complications:

• Insertion problems (injury to the radial sensory nerve)
• Late problems (infected pin sites)

The former can be mitigated by limiting the number of times a pin is placed, the latter by appropriate pin care. Although there is no consensus on appropriate pin care, most agree that the pin site should be kept clean and that showering is helpful. Early oral antibiotic therapy is usually successful in controlling pin site problems; if not, prompt pin removal usually cures the problem. Osteomyelitis is rare (< 1% of cases).

External fixation

External fixation also has two areas of complications:

• Insertion problems (injury to the radial sensory nerve, tendon injuries, and open section defects in the bone)
• Late problems (infected pin sites)

Insertion problems were addressed in 1990 by Seitz, who advocated open pin placement.[52] Insertion problems with this technique should be rare. As with percutaneous pinning, early oral antibiotic therapy is usually successful for controlling pin-site problems; if not, prompt pin removal usually cures the problem.

Dorsal plates

Dorsal plate complications are primarily related to the close apposition of the extensor tendons to the bone. Whereas many plates claim to be low-profile to avoid this problem, 2-mm plates in a 1-mm space are still too large and may cause tendon irritation. Tendon rupture is also a potential problem, likely related to specific plate design or application and perhaps influenced by the composition of the fixation device. Many authors routinely remove their plates. The dorsal approach has largely been relegated to fractures that can only be addressed via this approach.

Volar plates

Volar-plate complications are only now becoming identified, and they can be classified as either dorsal or volar problems.

Dorsal problems are related to past-pointing of the distal screws (ie, screw tips extending beyond the bone). Most orthopedic screws are designed with cutting flutes at the tip, and optimum bicortical purchase requires an amount of past-pointing approximately equal to one screw diameter. However, because of the design of most volar fixation systems in which the screws lock to the plate, the dorsal cortex does not offer additional fixation. Additionally, the dorsal cortex is thin and often comminuted.

Thus, secure fixation comes from the plate and the subchondral bone. Any past-pointing of the distal screws endangers the extensor tendons, which are in close apposition to the bone.[53] For a case example, see David Nelson, Case 2.

Volar problems with volar plates come from contact of the tendons with the plates, particularly with titanium plates. This can be due to poor plate design (eg, extension distal to the PQ, out over the volar capsule, or excessive thickness at the distal margin of the plate so that it extends volar to the PQ) or to loss of reduction, so that the flexor tendons are forced to use the plate as a fulcrum.

Spanning plates

Spanning plates require a second surgical procedure for plate removal. Although removal is not a complication per se, in that it is planned, it is a drawback to the procedure that is not shared by the other techniques used to treat DRFs.

There has been considerable discussion of the use of vitamin C in DRFs to prevent complex regional pain syndrome (CRPS), as a consequence of its inclusion in clinical guidelines published by the AAOS. Vitamin C was included in the guidelines in accordance with the original framework of the publication, which was to include recommendations that had good supporting literature. Unfortunately, the "supporting literature" consisted of two papers by the same group. A later meta-analysis by Evaniew et al found that the quality of the data was low and was insufficient to support recommendation of vitamin C for this purpose.[54] Patient or provider preference should be followed.

Fractures treated with a cast require close follow-up to observe for subsidence. Although fractures that have been reduced are most at risk, even fractures that were accepted and not reduced can still subside further and necessitate reassessment. The general rule for fractures that were reduced is to obtain a radiograph at weekly intervals for the first 3 weeks, with care taken to compare the current film with the original reduction film; minor degrees of subsidence may not be evident if the current film is compared only with the most recent film.

Instability and the likelihood of further subsidence are demonstrated by any loss of the original reduction. A common error is to accept the minor increase in loss of reduction at each week, expecting that the subsidence will cease, and then to discover at 3 weeks or later that the current alignment is unacceptable after the fracture has healed and is not reducible by closed means.

Fractures stabilized operatively should be followed at 7-10 days, as the surgeon prefers. Subsidence is rarely an issue, but the possibility should be evaluated by means of radiography.