Introduction & Epidemiology
Distal radius fractures are among the most common fractures encountered in orthopedic practice, representing approximately one-sixth of all fractures treated in emergency departments. Their incidence demonstrates a bimodal distribution, with peaks in younger, active individuals due to high-energy trauma, and in older adults, predominantly postmenopausal women, due to low-energy falls on an outstretched hand (FOOSH) associated with osteoporosis. The increasing prevalence of osteoporosis in an aging population contributes significantly to the rising incidence of these fractures globally.
The classification of distal radius fractures is critical for guiding treatment and prognosis. Commonly employed systems include the Frykman classification (based on articular involvement and ulna styloid fracture), the Fernandez classification (based on fracture mechanism and stability), the AO/OTA classification (a comprehensive alphanumeric system detailing location, articular involvement, and comminution), and the Universal classification. While various systems exist, the AO/OTA classification (23-A, 23-B, 23-C) is widely accepted for its detailed description and prognostic utility, particularly in research and surgical planning. Intra-articular involvement (23-C type fractures) and significant comminution are generally associated with poorer outcomes and often necessitate operative intervention.
The goal of treatment, whether operative or non-operative, is to restore anatomical alignment, achieve stability, and optimize functional outcomes. Parameters for acceptable reduction typically include:
* Radial inclination: 22-23 degrees (normal range 15-28 degrees)
* Radial length: 11-12 mm (normal range 8-18 mm)
* Palmar tilt: 11-12 degrees (normal range 0-22 degrees, with dorsal tilt generally unacceptable)
* Articular step-off: Less than 1-2 mm
* Gap between fragments: Less than 1-2 mm
Failure to achieve or maintain these parameters, particularly in displaced intra-articular fractures, significantly increases the risk of post-traumatic arthritis, chronic pain, and functional impairment.
Surgical Anatomy & Biomechanics
A thorough understanding of the intricate anatomy and biomechanics of the distal radius and radiocarpal joint is paramount for effective surgical management.
Osteology
The distal radius flares to articulate with the carpus and distal ulna. Key anatomical landmarks include:
*
Radial Styloid:
Most lateral projection, serving as an attachment for the brachioradialis tendon and the radial collateral ligament.
*
Lister's Tubercle (Dorsal Tubercle):
A prominent bony ridge on the dorsal aspect, acting as a pulley for the extensor pollicis longus (EPL) tendon. It separates the second and third dorsal compartments.
*
Sigmoid Notch:
Concave articular surface on the medial aspect, articulating with the distal ulna to form the distal radioulnar joint (DRUJ).
*
Articular Surfaces:
The distal radius has two distinct articular facets: the scaphoid fossa laterally and the lunate fossa medially. These are separated by a subtle ridge. Palmar tilt (average 11-12 degrees) and radial inclination (average 22-23 degrees) are critical for normal wrist mechanics.
Ligamentous Anatomy
The stability of the wrist is heavily reliant on a complex network of extrinsic and intrinsic ligaments.
*
Extrinsic Ligaments:
Connect the radius or ulna to the carpal bones.
*
Palmar Radiocarpal Ligaments:
The strongest and most important for stability. Includes the radioscaphocapitate, radiolunotriquetral, and short radiolunate ligaments. They prevent excessive wrist hyperextension and ulnar deviation. Damage often leads to carpal instability.
*
Dorsal Radiocarpal Ligaments:
Weaker than palmar ligaments, primarily the dorsal radiotriquetral ligament.
*
Triangular Fibrocartilage Complex (TFCC):
A critical structure stabilizing the DRUJ and suspending the carpus from the ulna. It comprises the articular disc, meniscal homologue, dorsal and palmar radioulnar ligaments, and the sheath of the extensor carpi ulnaris (ECU) tendon. TFCC injuries, particularly involving the foveal attachment of the palmar radioulnar ligament, can lead to chronic DRUJ instability and pain.
*
Intrinsic Ligaments:
Connect carpal bones to each other (e.g., scapholunate, lunotriquetral ligaments). While not directly involved in distal radius fixation, their integrity can be compromised by significant intra-articular fractures, contributing to overall carpal instability.
Tendon Compartments
The dorsal aspect of the distal radius is divided into six fibrous compartments beneath the extensor retinaculum, each containing specific tendons:
*
First:
Abductor pollicis longus (APL), extensor pollicis brevis (EPB)
*
Second:
Extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB)
*
Third:
Extensor pollicis longus (EPL) - curves around Lister's Tubercle
*
Fourth:
Extensor digitorum communis (EDC), extensor indicis proprius (EIP)
*
Fifth:
Extensor digiti minimi (EDM)
*
Sixth:
Extensor carpi ulnaris (ECU)
Neurovascular Structures
- Radial Artery: Courses distally along the radial aspect, superficial to the scaphoid.
- Median Nerve: Located on the palmar aspect, deep to the flexor retinaculum. Vulnerable to direct injury, compression by hematoma, or post-operative scarring.
- Ulnar Artery and Nerve: Located on the ulnar aspect.
- Superficial Radial Nerve: Sensory nerve, courses subcutaneously along the radial aspect of the forearm and hand. Prone to iatrogenic injury during radial-sided approaches or superficial dissection.
Biomechanics
The distal radius bears approximately 80% of the axial load transmitted across the wrist, with the remaining 20% borne by the ulna via the TFCC. A critical biomechanical concept in distal radius fractures is the importance of restoring articular congruence and maintaining appropriate radial length, inclination, and palmar tilt. Malunion, particularly dorsal angulation or radial shortening, alters load distribution, increases stresses on the carpus and DRUJ, and can lead to degenerative changes and pain. Volar plating aims to restore the palmar tilt and support the lunate fossa, preventing collapse.
Indications & Contraindications
The decision for operative versus non-operative management of distal radius fractures is complex, weighing fracture characteristics, patient factors, and surgical risks.
Operative Indications
Surgical intervention is generally indicated for unstable fractures that cannot be adequately reduced or maintained by closed methods, or for those with significant articular involvement.
Absolute Indications:
* Open fractures.
* Fractures with associated acute neurovascular compromise that does not resolve with closed reduction.
* Irreducible fractures due to soft tissue interposition.
* Fractures with compartment syndrome.
Relative Indications (commonly for ORIF with volar locking plates):
*
Loss of Radial Length:
Greater than 2-3 mm compared to the contralateral wrist.
*
Radial Inclination:
Less than 15 degrees.
*
Dorsal Tilting:
Greater than 0-10 degrees (some literature accepts up to 20 degrees for elderly, low-demand patients in non-operative settings, but for operative candidates, correction to neutral or palmar tilt is targeted).
*
Intra-articular Step-off/Gap:
Greater than 1-2 mm.
*
Significant Comminution:
Especially metaphyseal or articular, indicating inherent instability.
*
Associated Carpal Instability:
Ligamentous injuries (e.g., scapholunate dissociation) or carpal fractures.
*
DRUJ Instability:
Associated with distal radius fracture (e.g., sigmoid notch involvement, TFCC avulsion).
*
Younger, Active Patients:
Higher functional demands justify aggressive pursuit of anatomical reduction.
*
Failed Closed Reduction and Casting:
Inability to achieve or maintain acceptable reduction parameters.
Contraindications
While few absolute contraindications exist, several factors may influence the choice of surgical approach or patient suitability.
Absolute Contraindications (to elective surgery):
* Active infection at the surgical site.
* Uncontrolled systemic comorbidities (e.g., severe coagulopathy, acute cardiac event) that preclude safe anesthesia or surgery.
Relative Contraindications / Cautions:
*
Severe Osteoporosis:
May lead to poor screw purchase, requiring careful plate selection (e.g., plates with more distal screw options, larger number of screws) or augmentation (e.g., cement).
*
Poor Skin Condition:
Significant soft tissue compromise, severe edema, or blistering may necessitate delayed surgery or external fixation as a temporizing measure.
*
Extremely Frail Patients:
With very low functional demands and significant comorbidities, for whom the risks of surgery may outweigh the potential benefits.
*
Non-compliant Patients:
Who may not adhere to post-operative rehabilitation protocols.
Table 1: Operative vs. Non-Operative Indications for Distal Radius Fractures
| Indication Type | Operative Management | Non-Operative Management |
|---|---|---|
| Fracture Pattern |
- Dorsal angulation > 0-10° (or > 20° for elderly, low-demand)
- Radial shortening > 2-3 mm - Radial inclination < 15° - Intra-articular step-off/gap > 1-2 mm - Significant comminution (dorsal or palmar) - Irreducible fractures - Open fractures - Associated carpal instability (ligamentous tears, carpal fractures) - DRUJ instability or articular involvement |
- Stable, extra-articular fractures
- Minimally displaced or undisplaced fractures - Acceptable reduction parameters achieved and maintained after closed reduction and casting: - Dorsal tilt < 0-10° (or < 20° for elderly, low-demand) - Radial shortening < 2-3 mm - Radial inclination > 15° - Intra-articular step-off/gap < 1-2 mm - Elderly, low-demand patients with significant comorbidities, even with some displacement (consider functional outcome vs. anatomical perfection) |
| Patient Factors |
- Younger, active patients with high functional demands
- Medically fit for surgery |
- Elderly, sedentary patients with low functional demands
- Significant comorbidities precluding surgery (e.g., uncontrolled cardiac disease) - Non-compliance anticipated with post-operative care (though this can also be a challenge for casting adherence) |
| Associated Injuries |
- Acute neurovascular compromise (unresolved by reduction)
- Compartment syndrome |
- No significant associated injuries requiring surgical intervention |
| Treatment Failure |
- Failure to achieve acceptable reduction after closed manipulation
- Loss of reduction in cast (secondary displacement) |
- Initial successful closed reduction and maintenance of acceptable parameters in cast |
Pre-Operative Planning & Patient Positioning
Meticulous pre-operative planning is crucial for successful outcomes and minimizing complications.
Pre-Operative Assessment
-
Clinical Evaluation:
- Thorough history (mechanism of injury, hand dominance, occupation, pre-existing wrist conditions, comorbidities, medications).
- Neurovascular examination (median, ulnar, radial nerve function; radial and ulnar pulses; capillary refill).
- Soft tissue assessment (open wounds, blistering, swelling, tenting).
- Assess for signs of compartment syndrome, particularly in high-energy trauma.
-
Radiographic Evaluation:
- Standard Views: Posteroanterior (PA), lateral, and oblique views of the wrist are essential.
- PA View: Assess radial inclination, radial length, ulnar variance, and carpal alignment.
- Lateral View: Assess palmar or dorsal tilt, displacement, and articular congruity. A true lateral view with the pisiform and scaphoid superimposed is critical.
- Oblique Views: Can highlight specific intra-articular fragments or subtle pathology.
- Contralateral Wrist X-rays: Useful for comparison, especially for radial length, inclination, and palmar tilt, which can vary between individuals.
- Computed Tomography (CT) Scan: Indicated for complex intra-articular fractures, particularly those with significant comminution, articular step-off, or when surgical planning requires detailed visualization of fragment orientation (e.g., die-punch fragments, lunate facet involvement). CT with 3D reconstructions can be invaluable.
Surgical Planning
- Fracture Classification: Utilize AO/OTA or other systems to categorize the fracture.
-
Implant Selection:
- Plate Type: Volar locking plates are the standard for most unstable distal radius fractures. They come in various designs (e.g., fixed angle, variable angle, specific for lunate/scaphoid fossae). The choice depends on the fracture pattern and surgeon preference. Dorsal plating may be considered for severe dorsal comminution or irreducible dorsal articular fragments, though volar plating is preferred due to lower complication rates (e.g., tendon irritation).
- Plate Size and Length: Appropriate for the metaphyseal and diaphyseal components.
- Screw Type and Length: Locking screws provide angular stability and do not rely on plate-bone compression. Non-locking cortical screws may be used proximally or for lag screw fixation of fragments.
- Surgical Approach: Predominantly volar (Henry's approach). Dorsal approaches (Thompson or midline) are less common due to tendon risks but may be necessary for specific fracture patterns.
- Reduction Strategy: Anticipate whether direct or indirect reduction techniques will be needed. Consider external fixation or K-wire scaffolding for severe comminution.
- Contingency Planning: Always have backup options (e.g., external fixator, alternative plates/screws) in case the primary plan encounters difficulties.
Patient Positioning
- Operating Table: Standard operating table with a radiolucent hand table for the affected limb.
- Arm Position: The arm is typically placed on the hand table, abducted 90 degrees and externally rotated, with the elbow flexed 90 degrees, allowing for full pronation and supination and clear fluoroscopic access.
- Tourniquet: A pneumatic tourniquet is applied to the upper arm to provide a bloodless field, typically inflated to 250 mmHg or 100 mmHg above systolic blood pressure.
- Fluoroscopy: The C-arm image intensifier should be positioned to allow for immediate PA and true lateral views without repositioning the patient or the arm. This usually involves placing the C-arm across the patient's chest.
- Draping: Standard sterile draping, ensuring the entire hand, wrist, and forearm are prepped and draped freely to allow for manipulation and assessment of reduction and rotation. The ipsilateral iliac crest should also be prepped if bone grafting is anticipated.
- Anesthesia: Regional anesthesia (e.g., supraclavicular or axillary block) often combined with general anesthesia. Regional blocks provide excellent post-operative pain control.
Detailed Surgical Approach / Technique
The standard surgical approach for unstable distal radius fractures is the Volar Henry's Approach to the distal radius, providing excellent exposure for volar locking plate fixation.
1. Incision and Dissection
- Skin Incision: A longitudinal skin incision, approximately 6-8 cm, is made on the palmar aspect of the distal forearm. It typically runs from the flexor wrist crease proximally along the radial border of the flexor carpi radialis (FCR) tendon. Avoid crossing the wrist crease perpendicularly to minimize scar contracture. Some surgeons prefer a curvilinear incision just ulnar to the FCR or a more zig-zag approach.
- Subcutaneous Dissection: Carefully incise the subcutaneous tissue. Identify and protect the palmar cutaneous branch of the median nerve and branches of the lateral antebrachial cutaneous nerve, which lie subcutaneously.
- Superficial Fascia: Incise the superficial fascia.
- FCR Tendon Sheath: Identify the FCR tendon. The incision should be made longitudinally along the ulnar border of the FCR tendon sheath. Retract the FCR tendon radially. This internervous plane is between the FCR (median nerve innervation) and the flexor digitorum superficialis/flexor pollicis longus (FPL) (median nerve innervation). While technically not a true internervous plane based on different nerve supply, it's a safe and commonly used plane for distal radius exposure.
- Pronator Quadratus (PQ) Muscle: Deep to the FCR tendon and the flexor tendons, the rectangular fibers of the pronator quadratus muscle are identified, originating from the distal ulna and inserting into the distal radius. The FPL tendon and its vascular leashes are typically retracted ulnarly, or occasionally split longitudinally if necessary.
- PQ Release: The PQ is carefully elevated from its radial insertion, moving ulnarly. The tendinous origin of the FPL from the interosseous membrane should be released if required for sufficient exposure. The volar aspect of the distal radius is now exposed. Careful dissection is needed to protect the median nerve and radial artery, which lie ulnar to the FPL.
2. Fracture Reduction
- Hematoma Evacuation: Decompress the fracture site by evacuating hematoma. Inspect for irreducible fragments or interposed soft tissue.
- Manual Traction & Ligamentotaxis: Apply longitudinal traction to the hand and wrist. This often provides preliminary reduction through ligamentotaxis, particularly for extra-articular components.
-
Direct Reduction:
- Periosteal Elevation: Gently elevate the periosteum from fracture fragments, minimizing stripping to preserve vascularity.
- Joy-Stick K-wires: For larger, displaced fragments, particularly articular fragments (e.g., lunate facet, radial styloid), 1.0-1.25 mm K-wires can be inserted into the fragments and used as "joy-sticks" to manipulate them into anatomical position.
- Impaction: Disimpact any impacted fragments.
- Articular Surface Restoration: The primary goal is restoration of the articular surface. Use ball-tipped or blunt probes to elevate depressed articular fragments from the palmar side, restoring articular congruity. Often, a temporary K-wire is driven obliquely across the articular surface to hold these fragments in place, avoiding penetration of the joint.
- Metaphyseal Reduction: Once the articular surface is reduced, address the metaphyseal component. Restore radial length, inclination, and palmar tilt using direct manipulation, bone spreaders, or reduction clamps. The plate itself can often act as a reduction aid.
- Provisional Fixation: Once reduced, fragments are temporarily held with K-wires. Fluoroscopic views (PA, true lateral, oblique) are essential to confirm anatomical reduction in all planes, ensuring acceptable radial length, inclination, palmar tilt, and articular congruence (<1-2 mm step-off/gap).
3. Plate Application and Fixation
- Plate Positioning: Select an appropriate volar locking plate. The plate is positioned on the volar aspect of the distal radius. Crucially, the distal edge of the plate should be placed approximately 2-3 mm proximal to the watershed line (an imaginary line representing the most distal safe point to place hardware without impinging on the flexor tendons or median nerve during wrist extension). Proper plate placement is critical to prevent flexor tendon irritation or rupture.
- Proximal Fixation: Secure the plate to the radial shaft with at least two locking screws proximally. Ensure good cortical purchase.
-
Distal Fixation (Articular Support):
- Fixed-Angle Plates: Guide wires or drill sleeves are used to direct fixed-angle locking screws into the distal fragments, providing subchondral support. These screws engage the bone fragments and provide angular stability to prevent collapse.
- Variable-Angle Plates: Offer more flexibility in screw trajectory, allowing the surgeon to target specific fragments or avoid critical structures (e.g., previous K-wire holes).
- Subchondral Support: Aim to place multiple locking screws into the subchondral bone of the lunate and scaphoid fossae to create a stable "raft" supporting the articular surface. Ensure screws are bicortical proximally but unicortical distally, or very carefully bicortical while avoiding dorsal articular penetration. Fluoroscopy is critical to confirm screw length and avoid joint penetration or dorsal tendon irritation.
- Lag Screws (if indicated): For specific large, oblique fragments, a non-locking lag screw can be inserted through an oblong hole in the plate or an independent screw hole to provide interfragmentary compression before applying locking screws.
- Bone Grafting (if indicated): If there is significant metaphyseal bone loss or comminution, particularly in osteoporotic bone, autogenous cancellous bone graft (from the distal radius itself, olecranon, or iliac crest) or allograft/bone substitute may be packed into the defect to provide structural support and promote healing. This is particularly important under reduced articular fragments.
- Final Fluoroscopy: Obtain multiple intra-operative fluoroscopic images (PA, true lateral, obliques) to confirm optimal plate position, screw length, anatomical reduction, and stability. Assess the DRUJ for stability.
4. Wound Closure
- Pronator Quadratus Repair: Reattach the pronator quadratus muscle (if elevated) over the plate using absorbable sutures. This provides a soft tissue buffer between the plate and the flexor tendons/median nerve, reducing the risk of tendon irritation and adhesion.
- Fascial Closure: Close the deep fascia.
- Subcutaneous Closure: Close the subcutaneous tissue.
- Skin Closure: Close the skin with non-absorbable sutures or staples.
- Dressing: Apply a sterile dressing, followed by a sugar-tong splint or volar splint, typically in a neutral position or slight wrist extension, to provide comfort and protection.
Complications & Management
Despite advancements in surgical techniques and implants, complications can occur following distal radius ORIF. Proactive identification and appropriate management are critical.
Table 2: Common Complications, Incidence, and Salvage Strategies
| Complication | Incidence (%) | Salvage Strategies |
|
Infection
| 1-5% | - Prompt debridement and irrigation
- Culture-guided antibiotics (systemic)
- For persistent infection, consider implant removal (if fracture stable enough) or delayed placement of fixation after infection control
- Soft tissue coverage procedures (flaps) if needed. |
|
Delayed Union / Nonunion
| 5-10% | - Persistent pain and instability.
- Revision ORIF with bone grafting and plate augmentation (e.g., locking plate for non-union, or revision to a stronger plate).
- For failed fixation, consider external fixation with bone grafting.
- Salvage for established nonunion often involves vascularized bone grafts, or total wrist arthrodesis for recalcitrant cases. |
|
Malunion
| 10-30% | - Symptomatic malunion (pain, restricted ROM, arthritis): Corrective osteotomy and internal fixation.
- For subtle asymptomatic malunion, monitor.
- If degenerative changes are significant, consider salvage procedures (e.g., wrist arthrodesis, proximal row carpectomy, total wrist arthroplasty, depending on severity and patient factors). |
|
Median Nerve Injury / Carpal Tunnel Syndrome (CTS)
| 2-10% (transient) | - Conservative management for mild post-op dysesthesias (rest, splinting, NSAIDs).
- If pre-existing CTS, consider carpal tunnel release at time of ORIF.
- For persistent severe symptoms post-op or worsening neurological deficits, prompt surgical exploration and neurolysis. Remove prominent hardware if contributing to compression. |
|
Medial Nerve Injury / Carpal Tunnel Syndrome (CTS)
| 2-10% (transient) | - Conservative management for mild post-op dysesthesias (rest, splinting, NSAIDs).
- If pre-existing CTS, consider carpal tunnel release at time of ORIF.
- For persistent severe symptoms post-op or worsening neurological deficits, prompt surgical exploration and neurolysis. Remove prominent hardware if contributing to compression. |
|
Neurovascular Injury
| <1% | -
Acute compromise:
Immediate closed or open reduction. If symptoms persist, urgent surgical exploration.
-
Delayed nerve compression (e.g., CTS):
Carpal tunnel release, sometimes with hardware removal.
-
Tendon Rupture (e.g., EPL):
Tendon transfer (e.g., EIP to EPL) is the primary surgical treatment. |
|
Post-Operative DRUJ Instability / Dislocation
| 5-10% (fracture-dependent) | - Non-operative for mild asymptomatic instability (immobilization).
- If symptomatic instability or dislocation: Closed reduction and immobilization. If persistently unstable, open reduction and internal fixation of ulnar styloid (if fractured), or direct repair of TFCC ligaments. May require K-wire transfixation of the DRUJ temporarily. |
|
Anesthesia-related complications
| <1% | - Anaphylaxis, cardiac arrest, stroke, nerve injury, respiratory compromise. |
|
Hardware Complications
| 2-10% | -
Screw pullout/loosening:
Revision ORIF with alternative fixation, bone grafting if required.
-
Plate prominence/tendon irritation/rupture:
Removal of hardware if fracture united. If symptoms severe and fracture not united, consider replacement with lower profile plate or revision to external fixation.
-
Pain due to hardware:
Removal of hardware after union. |
|
Carpal Instability (SNAC/SLAC Wrist, TFCC injury) | 5-10% | - If DRUJ instability: K-wire transfixation, repair of ulnar styloid fracture or TFCC.
- For chronic DRUJ pain/instability: Resection arthroplasty (Darrach), arthrodesis (Sauvé-Kapandji), or soft tissue reconstruction (palmar radioulnar ligament).
- For symptomatic carpal instability: Ligament repair or reconstruction (e.g., tenodesis), partial or total wrist arthrodesis, proximal row carpectomy (PRC). |
|
CRPS (Complex Regional Pain Syndrome type 1)
| 1-5% | - Aggressive physical and occupational therapy (early weight-bearing and mobilization are crucial).
- Pharmacological management (NSAIDs, gabapentinoids, tricyclic antidepressants, calcitonin).
- Regional sympathetic blocks. In rare cases, spinal cord stimulation.
- Refer to pain management specialist early. |
|
DRUJ Instability / Dislocation
| 5-10% (fracture-dependent) | - Non-operative for mild asymptomatic instability (immobilization).
- If symptomatic instability or dislocation: Closed reduction and immobilization. If persistently unstable, open reduction and internal fixation of ulnar styloid (if fractured), or direct repair of TFCC ligaments. May require K-wire transfixation of the DRUJ temporarily. |
| Loss of reduction / Screw prominence / Flexor tendon rupture | 2-10% (Tendon rupture <1%) | -
Loss of Reduction:
Early re-ORIF if anatomical parameters are not met, sometimes with alternative fixation. If non-surgical candidate, consider external fixation or accepting minor malunion in elderly.
-
Screw prominence:
Surgical removal of prominent screws/hardware. If hardware causing tendon irritation, remove hardware after fracture union (typically 6-12 months).
-
Tendon rupture (e.g., FPL):
Direct repair is rarely possible due to tendon retraction. Usually requires tendon transfer (e.g., flexor digitorum superficialis to FPL). |
|
Other (e.g., CRPS, stiffness, tendinopathy) | Variable | -
CRPS:
Early recognition and aggressive therapy including pharmacotherapy (e.g., gabapentinoids), sympathetic blocks, physical therapy.
-
Stiffness/Reduced ROM:
Intensive physical therapy, dynamic splinting. If soft tissue contracture, consider tenolysis or capsulotomy. If malunion is the cause, consider corrective osteotomy.
-
Tendinopathy:
Conservative treatment (rest, NSAIDs, physical therapy). If refractory, consider local corticosteroid injection or surgical debridement/release. |
|
Other (e.g., CRPS, stiffness, tendinopathy) | Variable | -
CRPS:
Early recognition and aggressive therapy including pharmacotherapy (e.g., gabapentinoids), sympathetic blocks, physical therapy.
-
Stiffness/Reduced ROM:
Intensive physical therapy, dynamic splinting. If soft tissue contracture, consider tenolysis or capsulotomy. If malunion is the cause, consider corrective osteotomy.
-
Tendinopathy:
Conservative treatment (rest, NSAIDs, physical therapy). If refractory, consider local corticosteroid injection or surgical debridement/release. |
| | | |
|
Wrist Stiffness / Limited Range of Motion (ROM)
| Common (variable) | - Aggressive physical and occupational therapy immediately post-op (within limits of fracture stability).
- Dynamic splinting programs.
- If soft tissue contracture persists, consider tenolysis or capsulotomy.
- If due to malunion, corrective osteotomy. |
|
Pain (various, e.g., median, ulnar, CRPS, malunion) | Common (variable) | -
For pain due to hardware:
Removal of hardware after fracture union.
-
For pain due to malunion:
Corrective osteotomy and internal fixation if symptomatic and function-limiting. If severe degenerative changes, consider salvage procedures (e.g., wrist arthrodesis, PRC, arthroplasty).
-
For pain due to CRPS:
See above.
-
For tendinopathy:
See above.
-
Persistent joint pain (post-traumatic arthritis):
Conservative (NSAIDs, injections, activity modification). If severe and debilitating, consider salvage procedures (e.g., wrist arthrodesis, PRC, arthroplasty, denervation). |
| | | |
|
CRPS (Complex Regional Pain Syndrome type 1)
| 1-5% | - Aggressive physical and occupational therapy (early weight-bearing and mobilization are crucial).
- Pharmacological management (NSAIDs, gabapentinoids, tricyclic antidepressants, calcitonin).
- Regional sympathetic blocks. In rare cases, spinal cord stimulation.
- Refer to pain management specialist early. |
|
Wrist Stiffness / Limited Range of Motion (ROM)
| Common (variable) | - Aggressive physical and occupational therapy immediately post-op (within limits of fracture stability).
- Dynamic splinting programs.
- If soft tissue contracture persists, consider tenolysis or capsulotomy.
- If due to malunion, corrective osteotomy. |
| | | |
|
Volar locking plates are advantageous due to fixed-angle stability and strong support for the distal fragments, especially in comminuted or osteoporotic bone. However, complications such as flexor tendon irritation or rupture (often FPL) can occur if the plate is positioned too distally on the watershed line. | |
Early recognition and management are crucial.
This includes appropriate patient education on warning signs, frequent follow-up, and prompt imaging/clinical evaluation for suspicion of complication. Revision surgery or specific treatment for nerve/tendon damage are often successful, but prevention through meticulous surgical technique and vigilant post-operative care is paramount. |
|
Neurovascular Injury
| <1% | -
Acute compromise:
Immediate closed or open reduction. If symptoms persist, urgent surgical exploration.
-
Delayed nerve compression (e.g., CTS):
Carpal tunnel release, sometimes with hardware removal.
-
Tendon Rupture (e.g., EPL):** Tendon transfer (e.g., EIP to EPL) is the primary surgical treatment. |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | |
