Editing Distal radius fracture (section)

=== 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>