A key opinion leader in the field of orthopedics discusses how he or she would manage and treat a difficult case presentation.

Number of surgical options available to repair distal radius fractures if surgery is selected

Distal radius fractures are common injuries that occur from a fall onto the outstretched hand. This case is a typical case seen in the emergency room. The diagnosis of a distal radius fracture can readily be made with standard plain radiographs of the wrist. Beyond the standard radiographic evaluation of volar tilt, radial inclination, radial height, and ulnar variance, I also recommend scrutinizing the films for additional information such as the extent of articular involvement, volar cortical displacement, amount of dorsal comminution, the presence of osteopenia, and the extent of any distal ulnar involvement. These additional data can provide details on late fracture instability if closed management is selected.

Asif M. Ilyas

Controversy exists as to the extent of reduction that should be undertaken in the emergency room. The advantages of a preliminary reduction include improving any deformity, helping to control soft tissue swelling, and providing a sense of whether closed fracture management is feasible. My preference, if available, is to proceed with a full closed reduction with sedation and fluoroscopy in the pediatric population. However, in the elderly population, as in this case, I recommend a gentle reduction with a hematoma block to correct any deformity and improve swelling and comfort.

Figure 1. Radiograph of the right wrist of a 63-year-old right-hand dominant woman fell on her right wrist. What would you do — a closed reduction, external fixator, volar plating, dorsal plating or use intramedullary nails?

Credit: Kelly JD

Figure 2. Lateral view of the right wrist

Figure 3. AP view of the right wrist

Surgical indications

Typical surgical indications for an isolated distal radius fracture include but are not limited to articular incongruity of more than 2 mm, loss of volar tilt more than 20° to 30°, and volar cortical displacement. These indications can be titrated up or down depending on the age and needs of the patient. It should be noted that despite the growing trend toward surgical management of these fractures, nonsurgical treatment can still reliably result in good functional outcomes at the expense of early function and residual deformity. When discussing treatment of distal radius fractures with my patients, bias towards surgical intervention is increased with decreasing age, higher occupational or recreational demands, need for earlier return of function, and patient preference for improved cosmesis.

A number of surgical options are available for repairing distal radius fractures when and if surgery is selected. They include but are not limited to percutaneous pinning, external fixation, fragment specific fixation, intramedullary nailing and various plating techniques. The literature abounds with articles qualifying the efficacy of each of these techniques. Frankly, each technique is indeed effective if applied to the appropriate fracture pattern in the appropriate manner. Recently there has been a strong trend toward locking volar plate fixation. This trend is predicated on its reliable and safe surgical approach, ability to be applied to the majority of fracture patterns, stable fracture fixation facilitating early return to function, a good complication profile, and positive clinical outcomes.

Treatment plan

In this case (see Figures 1-3), I would discuss with the patient a closed reduction and casting vs. operative repair, as both are valid choices. I would explain the risks and benefits of each treatment course. If casting is selected then reduction will be performed with a hematoma block and a cast applied for at least 4 weeks to 6 weeks. Use of the hand will be limited during that time and some residual deformity to the wrist and radiographic malunion may persist. However, once the fracture is healed and the wrist rehabilitated with therapy after cast removal, functional use of the wrist will return.

Alternatively, operative repair could be considered and would be my principal recommendation. My surgical indications in this case are excessive dorsal fracture angulation of more than 50°, the presence of multiple displaced articular fragments, extensive dorsal comminution, underlying osteopenia, and earlier mobilization of her dominant hand. I would utilize a volar locking plate as it would afford direct fracture reduction and stable locking peri-articular fixation, while also facilitating earlier return of motion. Postoperatively, cast or splint immobilization will not be necessary. Rather a soft dressing would be applied and immediate use of the hand with activities of daily living would be allowed. Formal outpatient therapy would begin within 1 week to 2 weeks of surgery.

References:

Arora R. J Bone Joint Surg Am. 2011;doi:10.2106/JBJS.J.01597.

Bruinsma WE. Distal radius fractures. In: Contemporary Surgical Management of Fractures and Complications. Ilyas AM, Rehman S, eds. 1st ed. Philadelphia: Jaypee Medical Publishers;2012;128-166.

Asif M. Ilyas, MD, is the program fellowship director of Hand Surgery at the Rothman Institute and an associate professor in the Department of Orthopaedic Surgery at Thomas Jefferson University in Philadelphia. He can be reached at asif.ilyas@rothmaninstitute.com

Disclosure: Ilyas has no relevant financial disclosures.