Editing Distal radius fracture (section)

=== Surgery ===
Surgery is generally indicated for displaced or unstable fractures.<ref>{{cite journal |last1=Ilyas |first1=Asif |last2=Richey |first2=Bradley |title=Distal Radius Open Reduction and Internal Fixation |journal=Journal of Medical Insight |date=2020 |volume=2022 |issue=1 |doi=10.24296/jomi/301 |s2cid=251525983 |url=https://jomi.com/article/301/Distal-Radius-Open-Reduction-and-Internal-Fixation |url-access=subscription }}</ref> The techniques of surgical management include [[Internal fixation|open reduction internal fixation]] (ORIF), [[external fixation]], [[percutaneous pinning]], or some combination of the above. The choice of operative treatment is often determined by the type of fracture, which can be categorized broadly into three groups: partial articular fractures, displaced articular fractures, and metaphyseal unstable extra- or minimal articular fractures.<ref name="Court-Brown 2015"/>

Significant advances have been made in ORIF treatments. Two newer treatments are fragment-specific fixation and fixed-angle volar plating. These attempt fixation rigid enough to allow almost immediate mobility, in an effort to minimize stiffness and improve ultimate function; no improved final outcome from early mobilization (prior to 6 weeks after surgical fixation) has been shown. Although restoration of radiocarpal alignment is thought to be of obvious importance, the exact amount of angulation, shortening, intra-articular gap/step which impact final function are not exactly known. The alignment of the DRUJ is also important, as this can be a source of a pain and loss of rotation after final healing and maximum recovery.{{cn|date=October 2020}}

An [[Arthroscopy|arthroscope]] can be used at the time of fixation to evaluate for soft-tissue injury and the congruity of the joint surface and may increase the accuracy of joint surface alignment<ref>{{cite journal |last1=Edwards |first1=Charles C. |last2=Haraszti |first2=Christopher J. |last3=McGillivary |first3=Gary R. |last4=Gutow |first4=Andrew P. |title=Intra-articular distal radius fractures: Arthroscopic assessment of radiographically assisted reduction |journal=Journal of Hand Surgery |date=1 November 2001 |volume=26 |issue=6 |pages=1036–1041 |doi=10.1053/jhsu.2001.28760 |pmid=11721247 }}</ref>  Structures at risk include the triangular fibrocartilage complex and the scapholunate ligament. Scapholunate injuries in radial styloid fractures where the fracture line exits distally at the scapholunate interval should be considered. TFCC injuries causing obvious DRUJ instability can be addressed at the time of fixation.{{citation needed|date=October 2020}}

Prognosis varies depending on dozens of variables. If the [[anatomy]] (bony alignment) is not properly restored, function may remain poor even after healing. Restoration of bony alignment is not a guarantee of success, as soft tissue contributes significantly to the healing process.

==== Little joint involvement ====
These fractures are the most common of the three groups mentioned above that require surgical management.<ref name="Court-Brown 2015"/> A minimal articular fracture involves the joint, but does not require reduction of the joint. Manipulative reduction and immobilization were thought to be appropriate for metaphyseal unstable fractures. However, several studies suggest this approach is largely ineffective in patients with high functional demand, and in this case, more stable fixation techniques should be used.<ref>{{cite journal |last1=McQueen |first1=M. M. |last2=Hajducka |first2=C. |last3=Court-Brown |first3=C. M. |title=Redisplaced unstable fractures of the distal radius |journal=The Journal of Bone and Joint Surgery. British Volume |date=1 May 1996 |volume=78-B |issue=3 |pages=404–409 |doi=10.1302/0301-620X.78B3.0780404 |pmid=8636175 }}</ref><ref>{{cite journal |last1=McQueen |first1=MM |last2=MacLaren |first2=A |last3=Chalmers |first3=J |title=The value of remanipulating Colles' fractures |journal=The Journal of Bone and Joint Surgery. British Volume |date=1 March 1986 |volume=68-B |issue=2 |pages=232–233 |doi=10.1302/0301-620X.68B2.3958009 |pmid=3958009 }}</ref><ref>{{cite journal |last1=Schmalholz |first1=Anders |title=Epidemiology of distal radius fracture in Stockholm 1981–82 |journal=Acta Orthopaedica Scandinavica |date=1 January 1988 |volume=59 |issue=6 |pages=701–703 |doi=10.3109/17453678809149429 |pmid=3213460 |doi-access=free }}</ref>

Surgical options have been shown to be successful in patients with unstable extra-articular or minimal articular distal radius fractures. These options include percutaneous pinning, external fixation, and ORIF using plating. Patients with low functional demand of their wrists can be treated successfully with nonsurgical management; however, in more active and fit patients with fractures that are reducible by closed means, nonbridging external fixation is preferred, as it has less serious complications when compared to other surgical options.<ref name="Court-Brown 2015"/> The most common complication associated with nonbridging external fixation is pin tract infection, which can be managed with antibiotics and frequent dressing changes, and rarely results in reoperation.<ref name="Court-Brown 2015"/> The external fixator is placed for 5 to 6 weeks and can be removed in an outpatient setting.<ref name="Court-Brown 2015"/>

If the fractures are unlikely to be reduced by closed means, open reduction with internal plate fixation is preferred.<ref name="Court-Brown 2015"/> Although major complications (i.e. tendon injury, fracture collapse, or malunion) result in higher reoperation rates (36.5%) compared to external fixation (6%), ORIF is preferred, as this provides better stability and restoration of the volar tilt.<ref name="Court-Brown 2015"/><ref>{{cite journal |last1=Gradl |first1=Georg |last2=Gradl |first2=Gertraud |last3=Wendt |first3=Martina |last4=Mittlmeier |first4=Thomas |last5=Kundt |first5=Guenther |last6=Jupiter |first6=Jesse B. |title=Non-bridging external fixation employing multiplanar K-wires versus volar locked plating for dorsally displaced fractures of the distal radius |journal=Archives of Orthopaedic and Trauma Surgery |date=1 May 2013 |volume=133 |issue=5 |pages=595–602 |doi=10.1007/s00402-013-1698-5 |pmid=23420065 |s2cid=10456360 }}</ref> Following the operation, a removable splint is placed for 2 weeks, during which time patients should mobilize the wrist as tolerated.<ref name="Court-Brown 2015"/>

==== Displaced intra-articular fractures ====
These fractures, although less common, often require surgery in active, healthy patients to address displacement of both the joint and the metaphysis. The two mainstays of treatment are bridging external fixation or ORIF. If reduction can be achieved by closed/percutaneous reduction, then open reduction can generally be avoided. Percutaneous pinning is preferred to plating due to similar clinical and radiological outcomes, as well as lower costs, when compared to plating, despite increased risk of superficial infections.<ref>{{cite journal |last1=Anderson |first1=Mark S. |last2=Ghamsary |first2=Mark |last3=Guillen |first3=Phillip T. |last4=Wongworawat |first4=Montri D. |title=Outcomes After Distal Radius Fracture Treatment With Percutaneous Wire Versus Plate Fixation: Meta-Analysis of Randomized Controlled Trials |journal=Journal of Surgical Orthopaedic Advances |date=2017 |volume=26 |issue=1 |pages=7–17 |pmid=28459418 |url=https://www.jsoaonline.com/archive/2017/distal-radius-fracture-treatment-percutaneous-wire/ |url-access=subscription }}</ref> Level of joint restoration, as opposed to surgical technique, has been found to be a better indicator of functional outcomes.<ref name="Court-Brown 2015"/>