Distal radius fracture non-operative treatment

Distal radius fracture Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Distal radius fracture from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
X Ray
CT
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Non-Operative Treatment
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Distal radius fracture non-operative treatment On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Distal radius fracture non-operative treatment All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Distal radius fracture non-operative treatment
CDC on Distal radius fracture non-operative treatment
Distal radius fracture non-operative treatment in the news
Blogs on Distal radius fracture non-operative treatment
Directions to Hospitals Treating Distal radius fracture
Risk calculators and risk factors for Distal radius fracture non-operative treatment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

Overview

The majority of distal radius fractures may be treated non-operatively. Those that are undisplaced or minimally displaced may be treated in a cast for 6 weeks. Mainly type I and type IIA Melone's fracture may be managed conservatively. In elderly, cast immobilization provided functional outcomes similar to those achieved with surgical treatments.

Non-Operative Treatment

• All distal radius fractures characterized by minor comminution, without or with minimal displacements can be considered for closed reduction and cast immobilization.
• Mainly type I and type IIA Melone's fracture can be managed conservatively.

Closed reduction and cast application for Distal end radius fracture. Source: Case courtesy by: Dr. Rohan A. Bhimani

• The fracture should be kept under closed observation to look for any re-displacement.
• Despite the widespread acceptance of immobilization in a plaster cast, questions remain regarding the optimum position, the duration of immobilization and the need to extend the cast proximal to elbow.
• No clear consensus exists as to the best position for immobilizing the wrist in plaster.
• Most surgeons immobilize distal radius fractures in some amount of palmar flexion on the principle that dorsal periosteal hinge provides stability.
• However, the optimal position of hand function is with the wrist in dorsiflexion.
• Immobilization of the wrist in palmar flexion has a detrimental effect on hand function because dorsiflexion at the wrist is needed for proper rehabilitation of fingers.
• Literature has shown in patients with distal radius fractures who are aged 60 years and older, cast immobilization provided functional outcomes similar to those achieved with surgical treatments.
• Cast immobilization had the worst radiographic outcome yet the lowest complication rate.
• The American Academy of Orthopedic Surgeons (AAOS) issued a clinical guideline on the treatment of distal radius fractures in 2009.
• Recommendations:
  • Rigid immobilization is suggested in preference to removable splints in nonoperative treatment for the management of displaced distal radius fractures.
  • For all patients with distal radius fractures, a post-reduction true lateral radiograph of the carpus is suggested for assessment of Distal Radio-Ulnar Joint (DRUJ) alignment.
  • Operative fixation is suggested in preference to cast fixation for fractures with post-reduction radial shortening greater than 3 mm, dorsal tilt greater than 10º, or intra-articular displacement or step-off greater than 2 mm.
  • Patients probably do not need to begin early wrist motion routinely after stable fracture fixation.
  • Adjuvant treatment of distal radius fractures with vitamin C is suggested for the prevention of disproportionate pain.

Closed Reduction Technique

• Closed management of a distal radius fracture involves first anesthetizing the affected area with a hematoma block, regional anesthesia, sedation or a general anesthetic.
• Manipulation generally includes first placing the arm under traction and unlocking the fragments. The deformity is then reduced with appropriate closed manipulations (depending on the type of deformity) reduction, after which a splint or cast is placed and an X-ray is taken to ensure that the reduction was successful.
• The cast is usually maintained for about 6 weeks.
• The general principle is to reverse the mechanism of injury.
• A fall on an outstretched hand will usually cause over-extension of the wrist joint, often with some radial deviation.
• Thus, the preferred position for this type of injury, following reduction, is flexion and ulnar deviation.
  
• During the follow-up period, it is necessary to repeat x-rays at about 1 week to confirm that the position is still acceptable.
• Following healing and cast removal a period of rehabilitation for recovery of strength and range of motion is necessary.

Complications of Non-Operative Treatment

Failure of non-operative treatment is common.

• Re-displacement to its original position even in a cast
• Stiffness
• Post traumatic osteoarthritis leading to wrist pain and loss of function
• Other risks specific to cast treatment include:
  • Compression of the swollen arm causing compartment syndrome or carpal tunnel syndrome
  • Reflex sympathetic dystrophy is a serious complication
  • Stiffness is universal following a prolonged period of immobilization and swelling