Initial assessment
Document:
- mechanism and hand dominance
- skin and swelling
- median-nerve symptoms
- tendon function
- associated ulnar-sided injury
Radiographs should describe:
- articular involvement
- dorsal/volar tilt
- radial height and inclination
- comminution
- translation
- ulnar variance
- carpal alignment
Stability
Features associated with loss of reduction include:
- substantial initial displacement
- dorsal comminution
- intra-articular involvement
- shortening
- advanced age/poor bone quality
No single radiographic criterion should be used in isolation.
Treatment goals
The aim is a painless, functional wrist. Anatomical restoration is particularly important in younger/high-demand patients and in unstable intra-articular injuries, but treatment should be individualized in frail older patients.
Non-operative treatment
Appropriate for stable or acceptably reduced fractures:
- reduction if needed
- well-moulded cast or splint
- early finger and elbow movement
- interval radiographs for fractures at risk of displacement
Operative options
- percutaneous K-wires
- volar locking plate
- external fixation
- fragment-specific fixation in selected complex injuries
Choice depends on fracture pattern, bone quality, soft tissues and patient needs.
Options include:
- percutaneous wires
- external fixation
- volar locking plate
- dorsal or fragment-specific fixation
- combinations for complex patterns
The goal is restoration of joint congruity and stable alignment while allowing appropriate rehabilitation.
Complications
- median neuropathy/carpal tunnel syndrome
- malunion
- stiffness
- complex regional pain syndrome
- EPL rupture
- flexor tendon irritation from prominent volar hardware
- DRUJ dysfunction
- post-traumatic arthritis
Assessment
Distal radius fractures vary from extra-articular stable injuries to complex intra-articular fractures with carpal instability.
Assess:
- age and functional demand
- mechanism and bone quality
- open injury
- median nerve symptoms
- skin swelling
- associated ulnar or carpal injury
Radiographs should be reviewed for:
- radial height
- radial inclination
- volar/dorsal tilt
- intra-articular step/gap
- comminution
- ulnar variance
- DRUJ relationship
Instability
Features suggesting loss of reduction include:
- marked comminution
- substantial initial displacement
- dorsal angulation
- intra-articular extension
- associated ulnar fracture
- advanced age/poor bone quality
The significance of radiographic parameters depends on patient demand and symptoms, but severe malalignment can compromise wrist and DRUJ mechanics.
Median nerve
Acute carpal-tunnel syndrome after distal radius fracture is a surgical concern. Progressive severe median-nerve dysfunction should not be dismissed as simple neurapraxia from swelling.
Non-operative management
Stable or acceptably reduced fractures can be managed with immobilisation and radiographic follow-up where appropriate.
The immobilisation position should avoid excessive flexion or ulnar deviation that increases carpal-tunnel pressure or stiffness.
Volar plate issues
Complications include:
- flexor tendon irritation/rupture if the plate is prominent distally
- extensor tendon injury from long screws
- median nerve symptoms
- loss of reduction
- intra-articular screw penetration
- stiffness
- CRPS
Careful fluoroscopic assessment of screw length and joint penetration is essential.
Malunion
Malunion can cause:
- altered wrist load
- reduced forearm rotation
- DRUJ incongruity
- ulnocarpal impaction
- cosmetic deformity
- pain
Corrective osteotomy is considered when deformity clearly correlates with functional limitation.
FRCS synthesis
Treatment should be described in terms of stability, articular congruity, DRUJ function, median nerve and patient demand, rather than choosing fixation from age alone.