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AAOS Clinical Practice Guideline Summary

Treatment of Distal Radius


Fractures

Abstract
David M. Lichtman, MD The clinical practice guideline is based on a systematic review of
(Chair) published studies on the treatment of distal radius fractures in
Randipsingh R. Bindra, MD, adults. None of the 29 recommendations made by the work group
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FRCS (Vice-Chair) was graded as strong; most are graded as inconclusive or


Martin I. Boyer, MD consensus; seven are graded as weak. The remaining five
Matthew D. Putnam, MD moderate-strength recommendations include surgical fixation,
rather than cast fixation, for fractures with postreduction radial
David Ring, MD, PhD
shortening >3 mm, dorsal tilt >10°, or intra-articular displacement
David J. Slutsky, MD or step-off >2 mm; use of rigid immobilization rather than
John S. Taras, MD removable splints for nonsurgical treatment; making a
William C. Watters III, MD postreduction true lateral radiograph of the carpus to assess dorsal
radial ulnar joint alignment; beginning early wrist motion following
Michael J. Goldberg, MD
stable fixation; and recommending adjuvant treatment with vitamin
Michael Keith, MD C to prevent disproportionate pain.
Charles M. Turkelson, PhD
Janet L. Wies, MPH
strued as including all proper meth-
Robert H. Haralson III, MD, Overview and Rationale ods of care or excluding methods of
MBA
care reasonably directed to obtaining
The treatment of distal radius fractures
Kevin M. Boyer the same results. The ultimate judg-
practice guideline was approved by the
Kristin Hitchcock, MLS ment regarding any specific proce-
American Academy of Orthopaedic
dure or treatment must be made in
Laura Raymond Surgeons (AAOS) on December 4,
light of all circumstances presented
2009. The purpose of the clinical prac-
by the patient and the needs and re-
tice guideline is to help improve treat-
sources particular to the locality or
ment based on the current best evi-
institution. In 5 years, this guideline
dence. Current evidence-based practice
will be revised in accordance with
standards demand that physicians use
new evidence, changing practice,
the best available evidence in their clin-
rapidly emerging treatment options,
ical decision making. To assist in this,
and new technology.
the guideline consists of a series of sys-
tematic reviews of the available litera-
ture regarding the treatment of distal Potential Harms and
radius fractures in adults. These system- Contraindications
atic reviews were conducted between
This clinical practice guideline was July 2008 and June 2009 and show Most treatments are associated with
approved by the American Academy
of Orthopaedic Surgeons on where good evidence exists, where ev- some known risks, especially inva-
December 4, 2009. idence is lacking, and which topics must sive and surgical treatments. In addi-
be targeted in future research to im- tion, contraindications vary widely
J Am Acad Orthop Surg 2010;18:
180-189 prove the treatment of patients with dis- based on the treatment administered.
tal radius fractures. Therefore, discussion of available
Copyright 2010 by the American
Academy of Orthopaedic Surgeons. This guideline serves as an educa- treatments and procedures applica-
tional tool and should not be con- ble to the individual patient rely on

180 Journal of the American Academy of Orthopaedic Surgeons


David M. Lichtman, MD, et al

mutual communication between the the full clinical practice guideline, study with consistent findings, or
patient and physician. which is available at http://www. level I evidence from a single study
aaos.org/research/guidelines/drfguide for recommending for or against the
line.pdf. intervention or diagnostic).
Methods Grade strength: Weak. Overall qual-
The methods used to develop this ity of evidence: poor (level IV or V ev-
Recommendations idence from more than one study with
guideline were designed to combat
bias, enhance transparency, and pro- Each recommendation in this guide- consistent findings, or level II or III ev-
mote reproducibility. Their purpose line summary is accompanied by a idence from a single study for recom-
is to allow interested readers the grade indicating the strength of the mending for against the intervention or
ability to inspect all of the informa- recommendation, as follows: diagnostic).
tion the work group used to reach its Grade strength: Strong. Overall Grade strength: Inconclusive. Over-
decisions, and to verify that these de- quality of evidence: good (level I evi- all quality of evidence: none or con-
cisions are in accord with the best dence from more than one study flicting (the evidence is insufficient or
available evidence. The draft of this with consistent findings for recom- conflicting and does not allow a recom-
guideline was subject to peer review mending for or against the interven- mendation for or against the interven-
and public commentary before being tion or diagnostic). tion or diagnostic).
approved by the Board of Directors Grade strength: Moderate. Overall Grade strength: Consensus. Overall
of the AAOS. The methods used to quality of evidence: fair (level II or quality of evidence: no evidence (there
prepare this guideline are detailed in III evidence from more than one is no supporting evidence; in the ab-

From the Department of Orthopaedic Surgery, University of North Texas Health Science Center, and the Department of Orthopaedic
Surgery, John Peter Smith Hospital, Fort Worth, TX (Dr. Lichtman); the Department of Orthopaedic Surgery, Loyola University Medical
Center, Maywood, IL (Dr. Bindra); the Department of Orthopedic Surgery, Washington University Affiliated Hospitals, Washington
University School of Medicine, St. Louis, MO (Dr. Boyer); the Department of Orthopaedic Surgery, University of Minnesota,
Minneapolis, MN (Dr. Putnam); Massachusetts General Hospital Hand and Upper Extremity Service, Boston, MA (Dr. Ring); the
Slutsky Hand and Wrist Institute, Torrance, CA (Dr. Slutsky); The Philadelphia and South Jersey Hand Centers, Philadelphia, PA
(Dr. Taras); the Bone and Joint Clinic of Houston, Houston, TX (Dr. Watters); the Skeletal Dysplasia Clinic, Department of
Orthopaedics, Seattle Children’s Hospital, Seattle, WA (Dr. Goldberg); MetroHealth Medical Center, Cleveland, OH (Dr. Keith); and
the Department of Research and Scientific Affairs, (Dr. Turkelson, Ms. Wies, Mr. Boyer, Ms. Hitchcock, Ms. Raymond) and the
Department of Medical Affairs (Dr. Haralson), American Academy of Orthopaedic Surgeons, Rosemont, IL.
Dr. Lichtman or an immediate family member serves as a board member, owner, officer, or committee member of the Society of
Medical Consultants to the Armed Forces. Dr. Bindra or an immediate family member has received royalties from Tornier, is a
member of a speakers bureau or has made paid presentations on behalf of Small Bone Innovations and Integra NeuroSciences, and
serves as a consultant to or is a paid employee of Tornier and Integra Neurosciences. Dr. Boyer or an immediate family member
serves as a paid consultant to or is an employee of MiMedX Group and OrthoHelix Surgical Designs, serves as an unpaid consultant
to Pfizer and Synthes, has stock or stock options held in MiMedX Group and OrthoHelix Surgical Designs, and has received
nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as
paid travel) from Synthes. Dr. Putnam or an immediate family member has received royalties from Small Bone Innovations; is a
member of a speakers bureau or has made paid presentations on behalf of Wright Medical Technology; serves as a paid consultant
to or is an employee of Wright Medical Technology; has received research or institutional support from Biomet, Medtronic Sofamor
Danek, Synthes, and Zimmer; and has stock or stock options held in Amgen, Biomet, Merck, Stryker, Wright Medical Technology,
Boundary Medical, and MedConnections. Dr. Ring or an immediate family member has received royalties from DePuy and Wright
Medical Technology; serves as a paid consultant to or is an employee of Acumed and Wright Medical Technology; has received
research or institutional support from Acumed, Biomet, Stryker, Tornier, and Joint Active Systems; and has stock or stock options held
in MiMedX Group and Illuminoss Medical. Dr. Taras or an immediate family member serves as a board member, owner, officer, or
committee member of Union Surgical, is a member of a speakers bureau or has made paid presentations on behalf of Integra Life
Sciences, and has received research or institutional support from AxoGen. Dr. Watters or an immediate family member serves as a
board member, owner, officer, or committee member of the North American Spine Society, American Board of Spine Surgery, Board
of Advisors for the Official Disability Guidelines, and Med Center Ambulatory Surgery Center; is a member of a speakers bureau or
has made paid presentations on behalf of Stryker and Synthes; serves as a paid consultant to or is an employee of Orthofix and
Stryker; and has stock or stock options held in Intrinsic Therapeutics. Ms. Wies or an immediate family member has stock or stock
options held in Shering Plough. Dr. Haralson or an immediate family member serves as a paid consultant to or is an employee of
Medtronic and Medtronic Sofamor Danek and has stock or stock options held in Orthofix and AllMeds. None of the following authors
nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related
directly or indirectly to the subject of this article: Dr. Slutsky, Dr. Goldberg, Dr. Keith, Dr. Turkelson, Mr. Boyer, Ms. Hitchcock, and
Ms. Raymond.

March 2010, Vol 18, No 3 181


Treatment of Distal Radius Fractures

sence of reliable evidence, the work step-off >2 mm as opposed to cast thus making meta-analysis impossi-
group is making a recommendation fixation. ble. All had at least one method-
based on their clinical opinion consid- Recommendation strength: Moder- ologic flaw and were downgraded to
ering the known harms and benefits as- ate level II. The studies do not address
sociated with the treatment). Five randomized clinical trials met many important aspects of the surgi-
our inclusion criteria and compared cal treatment of distal radius frac-
Recommendation 1 fixation with cast immobilization.2-6 tures, including specific treatment of
We are unable to recommend for or Fracture instability is difficult to de- different fracture types (eg, volar rim
against performing nerve decompres- fine but was consistently defined fractures, fracture-dislocations).
sion when nerve dysfunction persists within these studies as loss of radio- Only 3 of 14 studies had statisti-
after reduction. graphic alignment after initial closed cally significant findings. In one
Recommendation strength: Incon- reduction and splinting. The studies study, there was only a statistically
clusive did not differentiate between articu- significant difference in complica-
We identified only one study that lar fractures and extra-articular frac- tions. In another study, there was a
enrolled patients with persistent tures, nor did they distinguish be- possibly clinically important differ-
nerve dysfunction after reduction of tween patient populations on the ence in the Disabilities of the Arm,
a distal radius fracture and that met basis of age. It was thus not possible Shoulder, and Hand (DASH) ques-
our inclusion criteria.1 This study to analyze these groups individually. tionnaire at 1 year but not at 3 or 6
used subjective symptoms and objec- There were differences in pain at 24 months. In the third study, there was
tive clinical tests to determine the and 52 weeks, but not 8 and 12 significantly better function at 2
persistence of nerve dysfunction after weeks, in one study; differences in years for percutaneous fixation com-
reduction. Only patients with symp- motion at 52 weeks in one study; pared with open reduction and inter-
toms and a positive clinical test un- and differences in complications, nal fixation. All other outcomes eval-
derwent nerve exploration (ie, carpal overall, in four studies. Complica- uated by the included studies were
tunnel release). Patients receiving tions were defined with variable cri- not statistically significant. It is
carpal tunnel release may have had teria and included carpal tunnel syn- therefore not possible to come to an
spontaneous improvement or may drome, thumb pain, ulnar nerve evidence-based conclusion for the
have benefited from surgery. The symptoms, and malunion. The differ- optimal surgical treatment of distal
spontaneous resolution of symptoms ences were all in favor of surgical radius fractures.
in patients not receiving carpal tun- treatment.
nel release may support this. Recommendation 5
Recommendation 4 We are unable to recommend for or
Recommendation 2 We are unable to recommend for or against surgical treatment of patients
We are unable to recommend for or against any one specific surgical aged >55 years with distal radius
against casting as definitive treat- method for fixation of distal radius fractures.
ment of unstable fractures that are fractures. Recommendation strength: Incon-
initially adequately reduced. Recommendation strength: Incon- clusive
Recommendation strength: Incon- clusive The available evidence does not
clusive Fourteen clinical trials met the inclu- demonstrate any difference between
This recommendation is inconclu- sion criteria: eight combined intra- casting and surgical fixation in pa-
sive because we did not identify any and extra-articular fractures,7-14 five tients aged >55 years.
qualifying studies investigating the studied only intra-articular frac- We questioned the role of surgical
role of conservative treatment in ade- tures,15-19 and one studied only extra- compared with nonsurgical treat-
quately reduced and maintained un- articular fractures.20 Inclusion was ment of unstable distal radius frac-
stable fractures. based on inadequate radiographic tures in the elderly, defined by age,
alignment after initial adequate infirmity, low functional demands,
Recommendation 3 closed reduction and splint immobi- and poor bone quality, with low-
We suggest surgical fixation for frac- lization. The studies did not allow energy injuries. We were unable to
tures with postreduction radial for stratification by fracture type. identify studies that distinguished
shortening >3 mm, dorsal tilt >10°, Only two treatment comparisons patients based on any of these fac-
or intra-articular displacement or were made by more than one study, tors apart from age. The cut-off age

182 Journal of the American Academy of Orthopaedic Surgeons


David M. Lichtman, MD, et al

for elderly patients has not been es- maintain consistency with other rec- was defined as acceptable alignment
tablished; we selected the age of 55 ommendations, the specified age in at initial presentation before any re-
years and found three clinical trials this recommendation is 55 years. No duction. Four clinical trials that com-
that did not include any patient aged differences in complications were pared cast to splint treatment met
<55 years.21-23 Two trials compared noted in the two groups. Patients the inclusion criteria.25,30-32 All had at
external fixation with cast immobili- aged >60 years and treated with least one methodologic flaw and
zation, and one trial compared per- volar locking plates or intrafocal pin- were downgraded to level II. Pain at
cutaneous pinning with cast immobi- ning did not experience tendon rup- 2 weeks was significantly lower in
lization. All had at least one ture, osteomyelitis, cellulitis, or com- casted patients in one of four trials.
methodologic flaw and were down- plex regional pain syndrome (CRPS) Pain at 6 or 8 weeks was signifi-
significantly more often in any one cantly lower in splinted patients in
graded to level II. One addressed
group. However, pin tract infections two of four trials. There were no sig-
extra-articular fractures; one, articu-
were unique to the pinning group. nificant differences in pain between
lar fracture; and one included both.
the two groups at other time inter-
The amount of pain experienced af-
Recommendation 7 vals. Complications, including loss
ter 1 year was not significantly dif-
We suggest rigid immobilization in of alignment, were largely similar for
ferent in patients treated with percu-
preference to removable splints when both groups. Both groups also had
taneous pinning or with a cast. There similar functional abilities, except
was also no significant difference in using nonsurgical treatment of the
management of displaced distal ra- for knife/fork use, which was signifi-
overall mental or physical health as cantly better in the splint group.32
dius fractures.
determined by the Medical Out- This resulted in the downgrading of
comes Study 36-Item Short Form Recommendation strength: Moder-
the recommendation to weak.
score and no significant difference in ate
the occurrence of complications in For the purposes of this recom-
mendation, we considered rigid im-
Recommendation 9
patients treated with percutaneous
mobilization to be immobilization We are unable to recommend for or
pinning or cast. However, percutane-
that was firm (eg, plaster, fiberglass) against immobilization of the elbow
ous pinning did have pin-related
and not intended for self-removal. in patients treated with cast immobi-
complications that do not occur in
Less-rigid immobilization was any lization.
the cast group. Both randomized
controlled trials that compared pa- type of wrap or brace that either in- Recommendation strength: Incon-
tients treated with external fixation completely immobilized the wrist or clusive
with casting found no statistically was intended to be removed by the For the purposes of this recom-
significant differences for pain after patient. Five level II randomized con- mendation, we considered immobi-
1 year. Similarly, no statistically sig- trolled trials met the inclusion lization of the elbow applied to
nificant differences were noted for criteria.25-29 There were significant prevent forearm rotation. One ran-
various functional activities. differences in pain at 5 to 6, 8, and domized controlled trial compared
24 weeks in favor of casting. There above-elbow to below-elbow splint-
Recommendation 6 was no significant difference in the ing for maintenance of reduction for
two groups at later follow-up. Al- 2 weeks after manipulative reduction
We are unable to recommend for or
though radial nerve symptoms oc- and found no differences.33 No other
against locking plates in patients
curred more often in patients treated outcomes were assessed; hence, data
aged >55 years who are treated sur-
with less-rigid immobilization, other are insufficient to critically evaluate
gically.
complication rates were not signifi- the need for elbow/forearm immobi-
Recommendation strength: Incon-
cantly different in the two groups. lization.
clusive
Locking plates have been pur-
Recommendation 8 Recommendation 10
ported to be beneficial for fixation of
osteoporotic fractures. A single level The use of removable splints is an Arthroscopic evaluation of the artic-
II prospective nonrandomized com- option when treating minimally dis- ular surface is an option during sur-
parative cohort study addressed this placed distal radius fractures. gical treatment of intra-articular dis-
recommendation by comparing volar Recommendation strength: Weak tal radius fractures.
locked plating with intrafocal pin- For the purposes of this recom- Recommendation strength: Weak
ning in patients aged >60 years.24 To mendation, minimal displacement Two studies met the inclusion cri-

March 2010, Vol 18, No 3 183


Treatment of Distal Radius Fractures

teria comparing surgical treatment of CT is an option to improve diagnos- distal radius fractures that are
distal radius fracture with or without tic accuracy for patterns of intra- treated nonsurgically be followed by
adjunctive wrist arthroscopy.34,35 articular fractures. ongoing radiographic evaluation for
Only one34 was sufficiently powered Recommendation strength: Weak 3 weeks and at cessation of immobi-
to detect the minimal clinically im- Arthroscopy can improve the eval- lization.
portant difference. Functional out- uation of carpal ligament lesions, but Recommendation strength: Con-
come was assessed by DASH scores. the included studies did not examine sensus
In the arthroscopy-assisted fixation the effect of these findings on patient This is a consensus recommenda-
group, the improvement in DASH outcome.36,37 The single study on the tion because of the lack of scientific
score at 3 months was clinically rele- use of CT demonstrated better frac- studies that examine the frequency of
vant in the arthroscopy group, but ture characterization but did not as- radiographic evaluation against dis-
the difference was not relevant at 1 sociate these findings with improved placement. Such studies may be lack-
and 2 years postoperatively. outcome.38 ing in part because of ethical con-
cerns about a control group without
Recommendation 11 Recommendation 13 radiographic follow-up.
Surgical treatment of associated liga- We are unable to recommend for or Redisplacement during nonsurgical
ment injuries (SLIL injuries, LT, or against the use of supplemental bone treatment of distal radius fractures may
TFCC tears) at the time of radius fix- grafts or substitutes when using lock- result in symptomatic malunions. If the
ation is an option. ing plates. fracture is noted to lose reduction dur-
Recommendation strength: Weak Recommendation strength: Incon- ing this period, then the surgeon and
clusive patient may agree to alter treatment.
One level II trial that compared the
There were no qualified studies This recommendation will involve pa-
arthroscopic reduction and fixation of
identified that addressed this recom- tient visits and radiographic assessment
distal radius fracture combined with ar-
mendation. that is already part of orthopaedic care
throscopic treatment of associated in-
of these injuries.
tracarpal ligament and triangular fibro-
cartilage complex (TFCC) injuries to Recommendation 14
fluoroscopic reduction and fixation of We are unable to recommend for or
Recommendation 16
the radius alone.33 In the arthroscopy against the use of bone graft (ie, au- We are unable to recommend whether
group, the DASH scores were clini- tograft, allograft) or bone graft substi- two or three Kirschner wires should be
cally important at the 3-month inter- tutes for the filling of a bone void as an used for distal radius fracture fixation.
val. Regardless of arthroscopy, the adjunct to other surgical treatments. Recommendation strength: Incon-
difference in function as determined Recommendation strength: Incon- clusive
by DASH scores was not relevant at clusive There were no qualified clinical
1 and 2 years postoperatively. The Only one study compared the use studies identified that addressed this
authors demonstrated that arthros- of allograft versus autograft after recommendation.
copy is a valuable adjunctive method dorsal plating.39 No difference in
for evaluating and treating these le- pain or function was observed. The Recommendation 17
sions that are not detectable on stan- authors did, however, report compli- We are unable to recommend for or
dard radiographs. One limitation of cations related to autograft harvest- against using the occurrence of distal
this study is the possibility that the ing. Several studies suggest some radius fractures to predict future fra-
observed carpal lesions may have benefit related to pain reduction gility fractures.
been preexisting. Additionally, the when calcium phosphate is used to Recommendation strength: Incon-
true incidence of carpal ligament le- support fixation.40-45 These studies clusive
sions in the fluoroscopy group was did not compare the outcome of fix- We identified six prospective co-
unknown. ation with and without the material hort studies reporting the occurrence
and hence are not applicable to this of fragility fractures after distal ra-
Recommendation 12 recommendation. dius fracture that met our inclusion
In patients with distal radius intra- criteria.46-51 The likelihood ratios for
articular fractures, arthroscopy is an Recommendation 15 the included studies have conflicting
option to improve diagnostic accu- In the absence of reliable evidence, it results. One of the six studies sug-
racy for wrist ligament injuries, and is the opinion of the work group that gests that a distal radius fracture

184 Journal of the American Academy of Orthopaedic Surgeons


David M. Lichtman, MD, et al

generates small but sometimes im- scaphoid distance; the other studied Recommendation 21
portant changes in the probability of scaphoid/lunate/triquetral bone over- A home exercise program is an op-
a future fragility fracture. The other lap to assess radioulnar alignment. tion for patients prescribed therapy
five studies suggest that distal radius Both of these studies are based on after distal radius fracture.
fracture alters the probability of a fu- level II evidence and showed that ac- Recommendation strength: Weak
ture fragility fracture to a small and curately performed lateral radio- Five randomized controlled trials
rarely important degree. Addition- graphs can reliably identify DRUJ compared a directed home exercise
ally, a diagnostic meta-analysis of the dislocation when associated with dis- program against various forms of su-
ability of distal radius to predict a tal radius fractures. pervised therapy.56-60 All had at least
future hip fracture shows low sensi-
one methodologic flaw and were
tivity and high specificity for predict-
Recommendation 20 considered level II evidence. By de-
ing future fragility fracture.
In the absence of reliable evidence, it sign, these studies excluded patients
is the opinion of the work group that with complications (finger stiffness,
Recommendation 18 CRPS), and their data reflect the ef-
all patients with distal radius frac-
We are unable to recommend for or fect of therapy in radius fractures
tures and unremitting pain during
against concurrent surgical treatment that were healing without any ad-
follow-up be reevaluated.
of distal radioulnar joint (DRUJ) in- verse events.
Recommendation strength: Con-
stability in patients with surgically In four of the five studies, patients
sensus
treated distal radius fractures. were treated with casting (with or
This recommendation is a consen-
Recommendation strength: Incon- without pins), and therapy was
sus statement because we were not
clusive started after removal of fixation (cast
able to identify relevant studies that
Two studies were found that inves- or external fixator). In one study, all
evaluated the effect of unremitting
tigated the functional outcome of patients were treated with volar plat-
DRUJ injuries.52,53 In both papers, pain and patient outcome after distal
ing and therapy was commenced 1
DRUJ instability was identified at radius fractures. week postoperatively.56 In studies
the conclusion of treatment. There- The pain associated with a distal comparing a directed home exercise
fore, no instabilities were diagnosed radius fracture will typically dimin- program with supervised therapy be-
or treated at the time of initial sur- ish after initiation of appropriate gun after removal of fixation, there
gery. Although these studies demon- treatment. Patients’ reports of unre- was no difference in pain or func-
strated that patients with DRUJ in- mitting pain during the early treat- tion. In the study in which patients
stability had poorer outcomes, ment period may signal a concomi- were mobilized 1 week after plating,
neither study addressed the question tant associated condition (eg, nerve the home exercise group had signifi-
whether early surgical intervention is irritation, nerve compression) that cantly better functional (patient-
indicated. requires investigation. The members rated wrist evaluation) scores than
of the work group deemed that issu- did the group that received formal
Recommendation 19 ing a recommendation on this topic therapy. The strength of this recom-
We suggest that all patients with dis- is warranted, despite the lack of evi- mendation was graded as weak
tal radius fractures receive a postre- dence to support or refute the inves- based on the possibly clinically im-
duction true lateral radiograph of the tigation into the source of unremit- portant effects identified by this
carpus to assess DRUJ alignment. ting pain following treatment. study.56
Recommendation strength: Moder- Patients undergoing treatment of dis-
ate tal radius fracture should report their Recommendation 22
In the presence of a distal radius frac- progress in recovery. When pain lev- In the absence of reliable evidence, it
ture, identification of associated DRUJ els do not decrease as expected, it is is the opinion of the work group that
dislocation can be difficult. We were in- appropriate to evaluate the patient patients perform active finger motion
terested in determining whether true lat- for causes of pain. This recommen- exercises following diagnosis of dis-
eral radiographs in a patient with a ra- dation may result in costs associated tal radius fractures.
dius fracture can identify DRUJ with assessment and management, Recommendation strength: Con-
dislocation to allow early intervention. but we believe these actions are con- sensus
Two studies addressed this ques- sistent with the current practice of Hand stiffness is one of the most
tion.54,55 One study used the piso- most orthopaedic surgeons. functionally disabling adverse effects

March 2010, Vol 18, No 3 185


Treatment of Distal Radius Fractures

following distal radius fracture. Stiff- lized with a fixator. In the volar plat- Recommendation strength: Incon-
ness of the fingers can result from a ing study, the control group patients clusive
combination of factors, including were fitted with a thermoplastic Two level II studies met the inclu-
pain, swelling, obstruction by splints splint that they were instructed to re- sion criteria because they evaluated
or casts, and apprehension or lack of move for showering; therefore, these wrist distraction with patient out-
understanding by the patient. Finger patients are not a reliable control come.64,65 There was no statistically
stiffness can be very difficult to treat group. The outcome measures used significant association between the
after fracture healing, requiring mul- were pain and function (DASH) amount of distraction and patient
tiple therapy visits and possibly addi- and/or complications. None of the outcome using a nonvalidated instru-
tional surgical intervention. Instruct- outcomes was significantly different ment. However, the work group
ing the patient at the first encounter between early and late motion. These agreed that the important potential
to move the fingers regularly and data support the recommendation adverse effect of finger stiffness was
not evaluated in these studies. It
through a complete range of motion that patients do not need to begin
would not be ethical to conduct a
may help to minimize the risk of this early wrist motion after stable frac-
prospective study to examine the ef-
complication. ture fixation.
fect of overdistraction; thus, the
Finger motion does not have any
work group has downgraded the rec-
adverse effects on an adequately sta- Recommendation 24 ommendation to inconclusive.
bilized distal radius fracture in re- To limit complications when external
gard to reduction or healing. This is fixation is used, limiting the duration Recommendation 26
an extremely cost-effective interven- of fixation is an option.
tion; it does not require pharmaceu- We suggest adjuvant treatment of
Recommendation strength: Weak
tical intervention or additional visits, distal radius fractures with vitamin C
Three prospective studies met the for the prevention of disproportion-
but it provides a significant impact
inclusion criteria. Collectively, these ate pain.
on patient outcome. Although finger
studies do not agree on a length of Recommendation strength: Moder-
stiffness is a critical adverse effect of
immobilization in a fixator; thus, we ate
distal radius fractures and directly
chose not to define a specific dura- We were interested in determining
affects patient outcome, the effects of
tion in the recommendation. The the potential benefit of nutritional
early finger motion cannot be ethi-
first study demonstrated no signifi- supplements in recovery of function
cally evaluated in a level I prospec-
tive study. The members of the work cant difference in groups treated after treatment of distal radius frac-
group therefore consider it important with external fixation for 5 weeks, tures. Two studies by the same group
to make this a recommendation by compared with 3 weeks of external met our inclusion criteria, and both
consensus opinion. fixation and 2 weeks of additional examined the use of vitamin C.66,67
casting.63 The results were reported Specifically, the studies found a sig-
Recommendation 23 using a nonvalidated patient out- nificant reduction in the incidence of
come score; hence, no clear effect CRPS after treatment of distal radius
We suggest that patients do not need
could be demonstrated by the early fracture when the patients were
to begin early wrist motion routinely
discontinuation of the external fix- given supplemental vitamin C. How-
following stable fracture fixation.
ator. Two additional studies that ever, these studies have a serious lim-
Recommendation strength: Moder-
used a nonvalidated patient outcome itation: there is no objective method
ate
score showed a statistically signifi- to conclusively diagnose CRPS, and
Three studies were included in this
cant association between poorer out- there is no method to assess outcome
recommendation.3,61,62 Each study in-
comes with prolonged external fixa- after CRPS. The authors used subjec-
vestigated different surgical treat-
tion.64,65 Based on limitations of the tive criteria to define a pain syn-
ment methods: volar plate, transsty-
outcome instruments, the strength of drome in these studies, which affects
loid fixation, or external fixation. In
recommendation was weak. the reliability of the data.
the two internal fixation studies,
therapy was started approximately at
1 week; in the external fixation Recommendation 25 Recommendation 27
study, mobilization was begun at 3 We are unable to recommend against Ultrasound and/or ice are options for
weeks. In two studies, the control overdistraction of the wrist when an adjuvant treatment of distal radius
group was either casted or immobi- external fixator is used. fractures.

186 Journal of the American Academy of Orthopaedic Surgeons


David M. Lichtman, MD, et al

Recommendation strength: Weak comes, the study did not address the fixation or plaster cast for severely
displaced Colles’ fractures? Prospective
We identified two prospective stud- question of whether early surgical in- 1-year study of 46 patients. Acta Orthop
ies that used patient outcome measures tervention is indicated. Scand 1990;61:528-530.
in regard to the effect of mechanical ad- 5. Howard PW, Stewart HD, Hind RE,
juvant treatment modalities for distal Recommendation 29 Burke FD: External fixation or plaster
for severely displaced comminuted
radius fractures.68,69 Neither study We are unable to recommend for or Colles’ fractures? A prospective study of
used validated patient outcome mea- against using external fixation alone anatomical and functional results. J Bone
sures to study the effect of interven- Joint Surg Br 1989;71:68-73.
for the management of distal radius
tion. The study examining the effect fractures in the presence of depressed 6. Pring DJ, Barber L, Williams DJ: Bipolar
fixation of fractures of the distal end of
of low-intensity ultrasound reported lunate fossa or four-part fracture the radius: A comparative study. Injury
statistically significant improvement (sagittal split). 1988;19:145-148.
in the number of patients with no Recommendation strength: Incon- 7. Egol K, Walsh M, Tejwani N, McLaurin
pain and with radiographic union.68 clusive T, Wynn C, Paksima N: Bridging
external fixation and supplementary
No long-term or permanent benefit No qualified studies were identi- Kirschner-wire fixation versus volar
related to a validated outcome mea- fied that addressed this recommenda- locked plating for unstable fractures of
the distal radius: A randomised,
sure was demonstrated. The second tion. prospective trial. J Bone Joint Surg Br
study demonstrated the value of ice No studies specifically investigated 2008;90:1214-1221.
at 3 and 5 days but showed no bene- distal radius fractures with depressed 8. van Manen CJ, Dekker ML, van Eerten
lunate fossa or four-part fractures PV, Rhemrev SJ, van Olden GD, van der
fit for pulsed electromagnetic field
Elst M: Bio-resorbable versus metal
therapy.69 that met our inclusion criteria. implants in wrist fractures: A
randomised trial. Arch Orthop Trauma
Surg 2008;128:1413-1417.
Recommendation 28
Future Research 9. Kreder HJ, Hanel DP, Agel J, et al:
We are unable to recommend for or Indirect reduction and percutaneous
against fixation of ulnar styloid frac- fixation versus open reduction and
The overall lack of strong recom- internal fixation for displaced intra-
tures associated with distal radius mendations reflects the need for articular fractures of the distal radius: A
fractures. more research into treatment of this randomised, controlled trial. J Bone
Joint Surg Br 2005;87:829-836.
Recommendation strength: Incon- common injury. Future studies
clusive 10. Harley BJ, Scharfenberger A, Beaupre
should also include a priori power LA, Jomha N, Weber DW: Augmented
Ulnar styloid fractures are rela- analyses to ensure that clinically im- external fixation versus percutaneous
tively common in association with portant improvements are measured pinning and casting for unstable
fractures of the distal radius: A
distal radius fractures. We were in- because these, rather than radio- prospective randomized trial. J Hand
terested in the effect of concomitant graphic outcomes alone, are the im- Surg Am 2004;29:815-824.
fixation of the styloid fracture on pa- provements that matter to patients. 11. Krishnan J, Wigg AE, Walker RW,
tient outcome. One study found no Slavotinek J: Intra-articular fractures of
the distal radius: A prospective
difference in radiographic appear-
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ance or patient outcomes between References static bridging and dynamic non-
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styloid fractures had poorer out- 4. Abbaszadegan H, Jonsson U: External 665-669.

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Treatment of Distal Radius Fractures

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