Nonsurgical Treatment of a Distal Radius Fracture: When & How?

Young Ho Shin; Jun O Yoon; Jae Kwang Kim

doi:10.12671/jkfs.2018.31.2.71

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Shin, Yoon, and Kim: Nonsurgical Treatment of a Distal Radius Fracture: When & How?

Review Article

J Korean Fract Soc 2018;31(2):71-78.

Published online: 10 April 2018

DOI: https://doi.org/10.12671/jkfs.2018.31.2.71

Nonsurgical Treatment of a Distal Radius Fracture: When & How?

Young Ho Shin, M.D., Jun O Yoon, M.D., Jae Kwang Kim, M.D., Ph.D.

Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Correspondence to: Jae Kwang Kim, M.D., Ph.D. Department of Orthopedic Surgery, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3523 Fax: +82-2-3010-8555 E-mail: orth4535@gmail.com

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Distal radius fractures are a common upper extremity fracture and a considerable number of patients have a stable fracture. In the treatment of distal radius fractures, there is considerable disagreement regarding the need for a strict anatomical restoration with operation in elderly patients. Therefore, nonsurgical treatment is a still important treatment option in distal radius fractures. The radiological parameters of before or after manual reduction are important for deciding whether to perform operation or not. The radiological parameters include dorsal angulation of the articular surface, radial shortening, extent of dorsal comminution, intra-articular displacement, concomitant ulnar metaphyseal fracture, shear fracture, and fracture-dislocation of the distal radioulnar joint. In addition, clinical situations of patients, including age, activity level, underline disease, and recovery level, which the patients wish should be considered, comprehensively. For the duration of a splint or cast, three to four weeks are recommended in impacted or minimally displaced fractures and five to six weeks in displaced fractures. After reduction of the displaced fractures, patients should undergo a radiologicical examination every week to check the redisplacement or deformity of the fracture site until two or three weeks post trauma. Arm elevation is important for controlling fracture site swelling and finger exercises, including metacarpophalangeal joint motion, are needed to prevent hand stiffness. Active range of motion exercise of the wrist should be initiated immediately after removing the splint or cast.

Keywords: Distal radius fracture, Nonoperative treatment, Dorsal tilt, Radial shortening

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Fig. 1.

Successful conservative treatment of a displaced distal radius fracture in a twenty year old woman. (A) Immediate post-trauma wrist anteroposterior and lateral X-ray. Dorsally displaced intra-articular distal radius fracture in the right wrist. (B) Wrist X-ray after manual reduction. Volar tilt of the distal radius and radial length were restored. (C) Wrist X-ray at post traumatic three months. The fracture site was well maintained and well united.

Fig. 2.

Result of conservative treatment of an elderly patient with a displaced distal radius fracture. X-rays of a seventy one-year-old woman. (A) Wrist anteroposterior and lateral X-ray after the initial reduction. Distal radius and ulnar styloid fracture with intra-articular comminution in the left wrist. The volar tilt and radial length were well restored after the reduction. (B) Wrist X-ray shows radial shortening and dorsal tilt of distal radius at 1 year after trauma. (C) Range of motion of the left wrist was decreased slightly compared to the right side, but she performed her daily activities without pain at 1 year after trauma.

Fig. 3.

Active finger range of motion exercise to prevent finger stiffness.

Table 1.

Summary of Randomized Controlled Trials for the Comparison between Non-Operative and Operative Treatment for Distal Radius Fractures

Article/ candidate of study	Type of treatment	Number	Mean age (yr)	Sex (men: women)	Severity of fracture (AO type) (n)	Clinical outcomes at final F/U (mean)			Radiologic outcomes (mean±standard deviation)
						Wrist flexion/ extension^*	Grip strength^*	Patient reported outcomes	Dorsal angulation (°)^†			Radial inclination (°)^†			Ulnar variance (mm)^†
						Wrist flexion/ extension^*	Grip strength^*	Patient reported outcomes	Pre	Post	F/U	Pre	Post	F/U	Pre	Post	F/U
Azzopardi et al.²⁰⁾ (2005)/ unstable, extraarticular fractures	Non-operative	27	71	2:25	A3	88.5%	72%	SF-36 physical (38.2)	29±16	—5±7	4±8	18±6	21±3	19±6	3±3	0±1	3±2
	Percutaneous pinning	27	72	4:23	A3	90.5%	77%	SF-36 physical (42.2)	35±15	—4±7	—3±10^‡	16±6	22±3	22±5	4±3	0±1	3±2
Wong et al.²¹⁾ (2010)/ unstable, extraarticular fractures	Non-operative	30	71	5:25	Frykman classification I:II (18:12)	143°	9.0 kg	Mayo wrist scores (80.5±7.5)	31±6	—7.5±1	3±1	13±3	23±4	16±2	4.3±1.2	0.5±0.2	3.2±1.4
Wong et al.²¹⁾ (2010)/ unstable, extraarticular fractures	Percutaneous pinning	30	70	6:24	Frykman classification I:II (17:13)	145°	8.5 kg	Mayo wrist scores (82.2±6.2)	33±6	—8±1	—4±1^‡	13±4	23±2	20±2^‡	5.2±1.8	0.3±0.1	2.1±1.1
Arora et al.²²⁾ (2011)/ displaced, unstable fractures	Non-operative	37	77.4	10:27	A2 (3), A3 (9), C1 (11), C2 (8), C3 (6)	103.7%^‡	92.6%	DASH scores (8.0±9.3)		3.6±11.2	10.4±19.1		20.3±3.3	15.9±9.0		0.8±1.7	3.2±2.9
Arora et al.²²⁾ (2011)/ displaced, unstable fractures	ORIF with volar locking plate	36	75.9	8:28	A2 (3), A3 (7), C1 (4), C2 (12), C3 (10)	92.8%	102.4%^‡	DASH scores (5.7±11.1)		—3.6±6.9^‡	—0.5±4.7^‡		21.8±2.7^‡	21.2±2.6^‡		0.6±1.6	0.7±1.8^‡
Sharma et al.²³⁾ (2014)/AO type B and C fractures	Non-operative	32	48.1	10:22	B (13), C (19)	135.0°	72.2%	DASH scores (14.0±10.2)		—8.4±0.4	—5.2±0.5		18.1±0.9	15.2±0.8		0.2±0.1	0.3±0.1
Sharma et al.²³⁾ (2014)/AO type B and C fractures	ORIF with volar locking plate	32	52.4	9:23	B (19), C (17)	168.2°^‡	89.1%^‡	DASH scores (5.0±9.4^‡)		—10.1±1.5^‡	—8.4±1.0^‡		20.5±1.3^‡	17.9±0.8^‡		—0.3±0.3	—0.3±0.2

^* Wrist flexion/extension arc and grip strength of the involved hand was presented as raw data or ratio compared to the contralateral side.

^† ‘ Pre’ means the values before the reduction or operation, ‘ Post’ means the values after the reduction or operation, and ‘ F/U’ means the values which were measured at the final follow-up period.

^‡ The value of this group was statistically significantly better than the comparison group. SF-36: 36-Item Short Form Health Survey, DASH: disabilities of the arm, shoulder and hand, ORIF: open reduction internal fixation.

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