Editing Distal radius fracture (section)

== Treatment ==
[[File:Posttraumatic arthritis of the wrist.jpg|thumb|Posttraumatic arthritis of the wrist, degeneration of the articular surface before and after resection]]
[[File:Wrist fusion.jpg|thumb|X-rays of a wrist fusion]]
[[File:Pins across a distal radius fracture.jpg|thumb|X-rays of pins across a distal radius fracture: Notice the ulnar styloid base fracture, which has not been fixed. This patient has instability of the DRUJ because the TFCC is not in continuity with the ulna.]]
Correction should be undertaken if the wrist radiology falls outside the acceptable limits:<ref name="Court-Brown 2015"/>
* 2-3mm positive ulnar variance<ref name="Court-Brown 2015"/>
* There should be no carpus malalignment<ref name="Court-Brown 2015"/> 
* If carpus is aligned, then the dorsal tilt should be less than 10 degrees<ref name="Court-Brown 2015"/>
* If carpus is aligned, there are no limits for palmar tilt<ref name="Court-Brown 2015"/>
* If carpus is malaligned, wrist tilt should be neutral<ref name="Court-Brown 2015"/>
* Gap or step deformity is less than 2mm<ref name="Court-Brown 2015"/>

Treatment options for distal radius fractures include nonoperative management, external fixation, and internal fixation.<ref name="Handoll et al 2018"/><ref>{{Citation|last1=Hsu|first1=Hunter|title=Wrist Fracture|date=2020|url=http://www.ncbi.nlm.nih.gov/books/NBK499972/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=29763147|access-date=2020-11-27|last2=Fahrenkopf|first2=Matthew P.|last3=Nallamothu|first3=Shivajee V.}}</ref> Indications for each depend on a variety of factors such as the patient's age, initial fracture displacement, and metaphyseal and articular alignment, with the ultimate goal to maximize strength and function in the affected upper extremity.<ref name="Court-Brown 2015">{{Cite book|title=Rockwood and Green's fractures in adults|others=Court-Brown, Charles M.,, Heckman, James D.,, McQueen, Margaret M.,, Ricci, William M.,, Tornetta, Paul, III,, McKee, Michael D.|isbn=978-1-4511-7531-8|edition=8th|location=Philadelphia|oclc=893628028|last1 = Court-Brown|first1 = Charles M.|last2=Heckman|first2=James D.|last3=McQueen|first3=Margaret M.|last4=Ricci|first4=William M.|last5=(Iii)|first5=Paul Tornetta|last6=McKee|first6=Michael D.|year=2015}}{{page needed|date=November 2021}}</ref> Surgeons use these factors combined with radiologic imaging to predict fracture instability, and functional outcome to help decide which approach would be most appropriate. Treatment is often directed to restore normal anatomy to avoid the possibility of malunion, which may cause decreased strength in the hand and wrist.<ref name="Court-Brown 2015"/> The decision to pursue a specific type of management varies greatly by geography, physician specialty (hand surgeons vs. orthopedic surgeons), and advancements in new technology such as the volar locking plating system.<ref>{{Cite journal|last1=Chung|first1=Kevin C|last2=Shauver|first2=Melissa J|last3=Birkmeyer|first3=John D|title=Trends in the United States in the Treatment of Distal Radial Fractures in the Elderly|journal=The Journal of Bone and Joint Surgery. American Volume|volume=91|issue=8|pages=1868–1873|doi=10.2106/jbjs.h.01297|pmid=19651943|pmc=2714808|year=2009}}</ref>

Distal radius fractures are often associated with distal radial ulnar joint (DRUJ) injuries, and the [[American Academy of Orthopaedic Surgeons]] recommends that postreduction lateral wrist X-rays should be obtained in all patients with distal radius fractures in order to preclude DRUJ injuries or dislocations.<ref>{{Cite web|url=http://www.orthoguidelines.org/guideline-detail?id=1042|title=OrthoGuidelines|website=www.orthoguidelines.org|access-date=2017-11-02}}</ref>

Most children with these types of fractures do not need surgery.<ref name="Handoll et al 2018"/>

=== Nonoperative ===
The majority of distal radius fractures are treated with conservative nonoperative management, which involves immobilization through application of plaster or splint with or without closed reduction.<ref name=":1">{{Cite book|title=Essentials of musculoskeletal care|date=2010|publisher=American Academy of Orthopaedic Surgeons|others=Sarwark, John F.|isbn=9780892035793|location=Rosemont, Ill.|oclc=706805938}}</ref> The prevalence of nonoperative approach to distal radius fractures is around 70%.<ref>{{Cite journal|last1=Court-Brown|first1=Charles M.|last2=Aitken|first2=Stuart|last3=Hamilton|first3=Thomas W.|last4=Rennie|first4=Louise|last5=Caesar|first5=Ben|title=Nonoperative Fracture Treatment in the Modern Era|journal=The Journal of Trauma: Injury, Infection, and Critical Care|volume=69|issue=3|pages=699–707|doi=10.1097/ta.0b013e3181b57ace|pmid=20065878|year=2010}}</ref> Nonoperative management is indicated for fractures that are undisplaced, or for displaced fractures that are stable following reduction. Variations in immobilization techniques involve the type of cast, position of immobilization, and the length of time required in the cast.<ref name="Court-Brown 2015"/>

====Undisplaced fractures====
For those with low demand, cast and splint can be applied for two weeks. In those who are young and active, if the fracture is not displaced, the patient can be followed up in one week. If the fracture is still undisplaced, cast and splint can be applied for three weeks. If the fracture is displaced, then manipulative reduction or surgical stabilisation is required. Shorter immobilization is associated with better recovery when compared to prolonged immobilization. 10% of the minimally displaced fractures will become unstable in the first two weeks and cause [[malunion]]. Therefore, follow up within the first week of fracture is important. 22% of the minimally displaced fractures will malunite after two weeks. Subsequent follow ups at two to three weeks are therefore also important.<ref name="Court-Brown 2015"/> There is weak evidence to suggest that some children with a buckle fracture may not require cast immobilization.<ref name="Handoll et al 2018"/>

Where the fracture is undisplaced and stable, nonoperative treatment involves immobilization. Initially, a backslab or a sugar tong splint is applied to allow swelling to expand and subsequently a cast is applied.<ref name=":1" /><ref name="Court-Brown 2015"/> Depending on the nature of the fracture, the cast may be placed above the elbow to control forearm rotation. However, an above-elbow cast may cause long-term rotational contracture.<ref name="Court-Brown 2015"/> For [[torus fracture]]s, a splint may be sufficient and casting may be avoided.<ref>{{cite web|url=http://www.bestbets.org/bets/bet.php?id=1009|title=BestBets: Is a cast as useful as a splint in the treatment of a distal radius fracture in a child}}</ref> The position of the wrist in cast is usually slight flexion and ulnar deviation. However, neutral and dorsiflex position may not affect the stability of the fracture.<ref name="Court-Brown 2015"/>

====Displaced fractures====
In displaced distal radius fracture, in those with low demands, the hand can be cast until the person feels comfortable. If the fracture affects the [[median nerve]], only then is a reduction indicated. If the instability risk is less than 70%, the hand can be manipulated under regional block or general anaesthesia to achieve reduction. If the post reduction radiology of the wrist is acceptable, then the person can come for follow up at one, two, or three weeks to look for any displacement of fractures during this period. If the reduction is maintained, then the cast should continue for 4 to 6 weeks. If the fracture is displaced, surgical management is the proper treatment. If the instability risk of the wrist is more than 70%, then surgical management is required. 43% of displaced fractures will be unstable within the first two weeks and 47% of the remaining unstable fractures will become unstable after two weeks. Therefore, periodic reviews are important to prevent malunion of the displaced fractures.<ref name="Court-Brown 2015"/>

Closed reduction of a distal radius fracture involves first [[Anesthesia|anesthetizing]] the affected area with a [[hematoma block]], [[intravenous regional anesthesia]] (Bier's block), [[sedation]] or a [[general anesthesia]].<ref name="Court-Brown 2015"/> Manipulation generally includes first placing the arm under traction and unlocking the fragments. The deformity is then reduced with appropriate closed manipulative (depending on the type of deformity)  [[Reduction (orthopedic surgery)|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.<ref name="Court-Brown 2015"/>

====Outcome of nonoperative treatment====
Failure of nonoperative treatment leading to functional impairment and anatomic deformity is the largest risk associated with conservative management. Prior studies have shown that the fracture often redisplaces to its original position even in a cast.<ref>{{cite journal|last1=Abbaszadegan|first1=H|last2=von Sivers|first2=K|last3=Jonsson|first3=U|year=1988|title=Late displacement of Colles' fractures|journal=Int Orthop|volume=12|issue=3|pages=197–9|doi=10.1007/BF00547163|pmid=3182123|s2cid=22597586}}</ref> Only 27-32% of fractures are in acceptable alignment 5 weeks after closed reduction.<ref>{{cite journal|last1=Earnshaw|first1=SA|last2=Aladin|first2=A|last3=Surendran|first3=S|last4=Moran|first4=CG|date=March 2002|title=Closed reduction of colles fractures: Comparison of manual manipulation and finger-trap traction: a prospective, randomized study|journal=J Bone Joint Surg Am|volume=84-A|issue=3|pages=354–8|pmid=11886903|doi=10.2106/00004623-200203000-00004|s2cid=23661205}}</ref> For those less than 60 years in age, there will be a dorsal angulation of 13 degrees, while for those older than 60, the dorsal angulation can reach as high as 18 degrees. In people over 60, functional impairment can last for more than 10 years.<ref name="Court-Brown 2015"/>

Despite these risks with nonoperative treatment, more recent systematic reviews suggest that when indicated, nonsurgical management in the elderly population may lead to similar functional outcomes as surgical approaches. In these studies,  no significant differences in pain scores, grip strength, and range of motion in patients' wrists occurred when comparing conservative nonsurgical approaches with surgical management. Although the nonsurgical group exhibited greater anatomic misalignment such as radial deviation, and ulnar variance, these changes did not seem to have significant impact on overall pain and quality of life.<ref>{{cite journal |last1=Ju |first1=Ji-Hui |last2=Jin |first2=Guang-Zhe |last3=Li |first3=Guan-Xing |last4=Hu |first4=Hai-Yang |last5=Hou |first5=Rui-Xing |title=Comparison of treatment outcomes between nonsurgical and surgical treatment of distal radius fracture in elderly: a systematic review and meta-analysis |journal=Langenbeck's Archives of Surgery |date=1 October 2015 |volume=400 |issue=7 |pages=767–779 |doi=10.1007/s00423-015-1324-9 |pmid=26318178 |s2cid=32745520 }}</ref>

=== 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"/>