We suggest operative fixation for fractures with post-reduction radial shortening >3mm, dorsal tilt >10 degrees, or intra-articular displacement or step-off >2mm as opposed to cast fixation.

Rationale
Five randomized clinical trials met our inclusion criteria and compared fixation to cast immobilization.24-28 All had at least one methodological flaw and were downgraded to Level II. All mixed articular fractures and extra-articular fracture in a manner which did not allow for separate analysis. There were no age criteria and the average patient age in these trials was similar to those that address treatment in older-aged patients (see Recommendation 5). There were differences in pain at 24 and 52 weeks, but not 8 and 12 weeks in one study, differences in motion at 52 weeks in one study, and differences in complications, overall, in 4 studies. The differences were all in favor of operative treatment. Complications included carpal tunnel syndrome, thumb pain, ulnar nerve symptoms, and malunion. The moderate strength of the data is therefore based primarily on differences in complications, which can be somewhat variably defined.

Fracture instability is difficult to define, but was consistently defined within these studies as loss of radiographic alignment after initial closed reduction and splinting in each of these trials.