Treatment of Distal Radius Fractures

• Median Neuropathy
  We are unable to recommend for or against performing nerve decompression when nerve dysfunction persists after reduction.
  Inconclusive
  There were no qualified studies identified that addressed this recommendation.
• Cast Treatment
  We are unable to recommend for or against casting as definitive treatment for unstable fractures that are initially adequately reduced.
  Inconclusive
  There were no qualified studies identified that addressed this recommendation.
• Indications for Fixation
  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.
  Moderate Evidence
  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.
• Fixation Technique
  We are unable to recommend for or against any one specific operative method for fixation of distal radius fractures.
  Inconclusive
  Fourteen clinical trials met the inclusion criteria: 8 combined intra- and extra- articular fractures,^29-36 5 studied only intra-articular fractures,^37-41 and one studied only extra-articular fractures.⁴² No studies evaluated shearing/articular rim fractures, or radiocarpal fracture-dislocations. Inclusion was based on inadequate radiographic alignment after initial adequate closed reduction and splint immobilization. Thus, the included studies did not allow for stratification by fracture type. Only two comparisons were made by more than one study making meta-analysis impossible. All had at least one methodological flaw and were downgraded to Level II. 
  
  The included studies in this recommendation do not address many important aspects of the operative treatment of distal radius fractures, including different operative treatments for different fracture types. Therefore, it is not possible to come to an evidence based conclusion for the optimal operative treatment of distal radius fractures.
  
  Only three of 14 studies had statistically significant findings. In one study, there was only a statistically significant difference in complications. In another study, there was a possibly clinically important difference in DASH at 1 year but not at 3 or 6 months.  In the third study, there was statistically significant better function at 2 years for percutaneous fixation over ORIF. All other outcomes evaluated by the included studies were not statistically significant.
• Surgical Age Limitations
  We are unable to recommend for or against operative treatment for patients over age 55 with distal radius fractures.
  Inconclusive
  We were interested in determining the role of operative treatment compared to non-operative treatment of patients defined by the published literature as “elderly” and that distinguished patients based on infirmity, functional demands, bone quality, or energy of injury. Three clinical trials met the inclusion criteria.^43-45 Two trials compared external fixation to cast immobilization and one trial compared percutaneous pinning to cast immobilization. All had at least one methodological flaw and were downgraded to Level II. One addressed extra-articular fractures, one articular fractures, and one both. Age criteria included age over 55 in 2 studies and over age 60 in one study. We selected the age of 55 because these included studies enrolled patients no younger than 55 years. We were unable to identify studies that distinguished patients based on infirmity, functional demands, bone quality, or energy of injury. The average patient age in these trials was comparable to those considered in Recommendation 3.  Inclusion was based on redisplacement in one study, initial radiographic alignment in one study, and instability not otherwise defined in one study.  There were no differences in pain, function, complications or SF-36 at any time point.
• Use of Locking Plates
  We are unable to recommend for or against locking plates in patients over the age of 55 who are treated operatively.
  Inconclusive
  We were interested in determining the role of locking plates compared to other operative techniques in the potentially osteoporotic population. A single level II prospective non-randomized comparative cohort study addressed this recommendation by comparing volar locked plating with intrafocal pinning.⁴⁶ The inclusion criteria specified age over 60, but for consistency with other recommendations, this recommendation specifies patients aged 55 and older.  No differences in complications were noted. 
• Rigid Immobilization for Displaced Fractures
  We suggest rigid immobilization in preference to removable splints when using non-operative treatment for the management of displaced distal radius fractures.
  Moderate Evidence
  For the purposes of this recommendation we considered rigid immobilization to be any form of immobilization that was firm (e.g. plaster, fiberglass) and not intended for self-removal, and less-rigid immobilization was any type of wrap or brace that either incompletely immobilized the wrist or was intended to be removed by the patient.  
  
  Five Level II randomized controlled trials met the inclusion criteria.^47-51  There were significant differences in pain at 5-6, 8 and 24 weeks in favor of casting. All other durations of follow-up did not have significant differences between patients treated with rigid immobilization or less-rigid immobilization. Radial nerve symptoms occurred more often in patients treated with less-rigid immobilization and no other complications were significantly different.
• Splint for Minimally Displaced Fractures
  The use of removable splints is an option when treating minimally displaced distal radius fractures.
  Limited Evidence
  For the purposes of this recommendation minimal displacement was defined as acceptable alignment after the initial injury and prior to any reduction. Rigid immobilization was any form of immobilization that was firm (e.g. plaster, fiberglass) and not intended for self-removal, and less-rigid immobilization was any type of wrap or brace that either incompletely immobilized the wrist or was intended to be removed by the patient.   
  
  Four clinical trials that compared cast to splint treatment met the inclusion criteria. ^{47, 52-54}  All had at least one methodological flaw and were downgraded to Level II.  There were no age criteria.
  
  Pain at 2 weeks was significantly lower in casted patients in one of 4 trials.  Pain at six or eight weeks was significantly lower in splinted patients in 2 of 4 trials. This resulted in the downgrading of the recommendation to “Limited.” All other durations of follow-up did not have significant differences between patients treated with less-rigid immobilization or rigid immobilization.
• Elbow Immobilization
  We are unable to recommend for or against immobilization of the elbow in patients treated with cast immobilization.
  Inconclusive
  For the purposes of this recommendation we considered immobilization of the elbow as immobilization of forearm rotation (pronation and supination). 
  
  One randomized controlled trial compared above elbow to below elbow splinting for maintenance of reduction for 2 weeks after manipulative reduction of unstable fracture and found no differences.⁵⁵  No other outcomes were assessed.
• Intraoperative Arthroscopy
  Arthroscopic evaluation of the articular surface is an option during operative treatment of intra-articular distal radius fractures.
  Limited Evidence
  There were two studies that met the inclusion criteria^{56, 57} but only one was sufficiently powered to detect the minimal clinically important difference.⁵⁶ In this study, arthroscopy assisted reduction of the articular surface.  In the arthroscopy group the DASH scores were clinically improved at the three month interval. Regardless of arthroscopy, the difference in function as determined by DASH scores was inconclusive at 1 and 2 years postoperatively. This resulted in a downgrading of the recommendation to “Limited.”
• Operative Treatment of Associated Carpal Ligament Injuries
  Operative treatment of associated ligament injuries (SLIL injuries, LT, or TFCC tears) at the time of radius fixation is an option.
  Limited Evidence
  There was one Level II trial that compared the arthroscopic reduction and fixation of distal radius fracture combined with arthroscopic treatment of associated intra carpal ligament and TFCC injuries to fluoroscopic reduction and fixation of the radius alone.⁵⁵ The authors demonstrated that arthroscopy is a valuable adjunctive method for evaluating and treating these lesions which are not detectable on standard radiographs. One limitation of the study is the possibility of preexisting carpal lesions. An additional limitation is that the true incidence of carpal ligament lesions in the fluoroscopy group was unknown. These limitations resulted in a downgrading of the recommendation to “Limited.” In the arthroscopy group, the DASH scores were clinically important at the three month interval. Regardless of arthroscopy, the difference in function as determined by DASH scores was inconclusive at 1 and 2 years postoperatively.
• CT and Adjunctive Arthroscopy
  Arthroscopy is an option in patients with distal radius intra articular fractures to improve diagnostic accuracy for wrist ligament injuries, and CT is an option to improve diagnostic accuracy for patterns of intra-articular fractures.
  Limited Evidence
  Arthroscopy can improve the evaluation of carpal ligament lesions but the included studies did not demonstrate the effect of this on patient outcome.^{58, 59}  The single study on the use of CT scanning demonstrated better fracture characterization but did not associate these findings with improved outcome.⁶⁰ Based on the lack of patient treatment outcome and concerns regarding the additional costs, the recommendation was downgraded to “Limited.”
• Supplemental bone grafts and Locking Plates
  We are unable to recommend for or against the use of supplemental bone grafts or substitutes when using locking plates.
  Inconclusive
  There were no qualified studies identified that addressed this recommendation.
• Supplemental Grafting as Adjunct to Other Operative Treatments
  We are unable to recommend for or against the use of bone graft (autograft or allograft) or bone graft substitutes for the filling of a bone void as an adjunct to other operative treatments.
  Inconclusive
  We were interested in determining the role of bone void fillers in addition to operative fracture fixation. Only one study compared the use of allograft versus autograft after dorsal plating.⁶¹ No difference in pain or function was observed. They did however report complications related to autograft harvestation.
  
  Several studies suggest some benefit related to pain reduction when calcium phosphate is used to support fixation.^62-67 These studies did not compare the outcome of fixation with and without the material and hence are not applicable to this recommendation. We cannot support or discredit the use of bone substitutes as an adjunct to operative fixation.
• Serial Radiography
  In the absence of reliable evidence, it is the opinion of the work group that distal radius fractures that are treated non-operatively be followed by ongoing radiographic evaluation for 3 weeks and at cessation of immobilization.
  Consensus
  Redisplacement during non-operative treatment of distal radius fractures may result in symptomatic malunions in any patient. The work group deemed that it is warranted to issue a recommendation on this topic despite a lack of evidence determining maintenance of adequate fracture reduction during non-operative treatment. Patients and surgeons may agree to alter treatment if the fracture is noted to lose reduction during this period. This recommendation will involve patient visits and radiographic assessment which is part of orthopedic care of these injuries. We believe that such monitoring of fracture position during non-operative treatment is consistent with the current practice of most orthopedic surgeons.
• Kirschner wire fixation
  We are unable to recommend whether two or three Kirschner wires should be used for distal radius fracture fixation.
  Inconclusive
  There were no qualified studies identified that addressed this recommendation.
• Prediction of Fragility Fractures
  We are unable to recommend for or against using the occurrence of distal radius fractures to predict future fragility fractures.
  Inconclusive
  Our intent was to investigate if there is an association between distal radius fractures and future fragility fractures. Based upon our evaluation of the likelihood ratio data, the evidence for this association was inconclusive.
• Surgery for Radioulnar Joint Instability
  We are unable to recommend for or against concurrent surgical treatment of distal radioulnar joint instability in patients with operatively treated distal radius fractures.
  Inconclusive
  We were interested in determining whether early surgical treatment of DRUJ instability performed at the same time as operative treatment of acute distal radius fractures provides improved patient outcomes.  Two studies were found that investigated the functional outcome of DRUJ injuries. ^{74, 75} The instabilities were identified at the conclusion of treatment.  Therefore no instabilities were treated at the time of surgery.  Although the patients with instability had poorer outcomes, neither study addressed the question of whether early operative intervention is indicated.
• Post-Reduction Imaging
  We suggest that all patients with distal radius fractures receive a post-reduction true lateral x-ray of the carpus to assess DRUJ alignment.
  Moderate Evidence
  It is common knowledge that in the presence of a DRUJ injury or distal radius fracture the injury itself can preclude identifying DRUJ dislocation.  In order to not miss this treatable injury which often occurs in association with distal radius fractures, we were interested in determining whether true lateral x-rays can identify DRUJ dislocation. Two studies addressed this question.^{76, 77} One study described the piso-scaphoid distance and the other studied scaphoid/lunate/triquetrum overlap. Because both of these studies are based on level II evidence and showed that accurately performed lateral x-rays can reliably identify DRUJ dislocation when associated with DRF, we made the recommendation that true lateral x-rays be obtained in patients with distal radius fractures.
• Re-evaluate Unremitting Pain
  In the absence of reliable evidence, it is the opinion of the work group that all patients with distal radius fractures and unremitting pain during follow-up be re-evaluated.
  Consensus
  The pain associated with a distal radius fracture will typically diminish after standard treatment protocols.  Patient’s reports of unremitting pain during the early treatment period may signal a concomitant associated condition which requires investigation. The work group deemed that it is warranted to issue a recommendation on this topic despite the lack of evidence to support or refute the investigation into the source of unremitting pain following treatment of distal radius fracture. Each patient in the treatment of distal radius fracture should report their progress in recovery. When pain levels do not decrease as expected, it is appropriate to evaluate the patient for causes of pain. This recommendation may result in costs associated with assessment and management. We believe these actions are consistent with the current practice of most orthopedic surgeons
• Home Exercise Program
  A home exercise program is an option for patients prescribed therapy after distal radius fracture.
  Limited Evidence
  We were interested in determining the role of formal therapy compared to non-formal therapy after distal radius fracture. Five randomized controlled trials compared a directed home exercise program against various forms of supervised therapy.^78-82 All had at least one methodological flaw and were considered level II evidence.
  
  In 4 of the 5 studies, patients were treated with casting (with or without addition of pins) and therapy was started after removal of fixation (cast or external fixator). In one study, all patients were treated by volar plating and therapy was commenced 1 week postoperatively.
  
  In studies comparing directed home exercise program to supervised therapy started after removal of fixation there was no difference in pain or function. We questioned the applicability of these studies because of the timing of therapy. In the remaining study where patients were mobilized 1 week after plating, the home exercise group had significantly better functional (PRWE) scores than the group that received formal therapy. The strength of recommendation was graded as “limited” based on the possibly clinically important effects identified by this study. 
  
  The above studies excluded, by design, patients with complications (finger stiffness, CRPS) and the data above reflect the effect of therapy in radius fractures that were healing without any adverse events.
• Finger Exercise
  In the absence of reliable evidence, it is the opinion of the work group that patients perform active finger motion exercises following diagnosis of distal radius fractures.
  Consensus
  Hand stiffness is one of the most functionally disabling adverse effects after distal radius fractures. Stiffness of the fingers can result from a combination of factors including pain, swelling, obstruction by splints or casts, and apprehension or lack of understanding by the patient. Finger stiffness can be very difficult to treat after fracture healing requiring multiple therapy visits and possibly additional surgical intervention. Instructing the patient at the first encounter to move their fingers regularly and through a complete range of motion may help to minimize the risk of this complication. Finger motion does not have any adverse effects on an adequately stabilized distal radius fracture with regard to reduction or healing. This is an extremely cost-effective intervention as it does not require any pharmaceutical intervention or additional visits while making a significant impact on patient outcome. Although finger stiffness is a critical adverse effect of distal radius fractures and directly impacts patient outcome, the effects of early finger motion cannot be ethically evaluated in a level I prospective study. The members of the work group feel it is important to make a recommendation by consensus opinion.
  
  It is current clinical practice for the treating physician to instruct every patient to move their fingers after distal radius fracture regardless of the type of treatment or immobilization selected. This recommendation is consistent with current practice.
• Timing of Rehabilitation
  We suggest that patients do not need to begin early wrist motion routinely following stable fracture fixation.
  Moderate Evidence
  Three studies were included in this recommendation.^{25, 83, 84} Each study investigated different operative treatment methods: volar plate, trans-styloid fixation or external fixation. Mobilization was commenced at different times, in the two internal fixation studies, therapy was started approximately at 1 week and in the external fixation study, mobilization was commenced at 3 weeks. In 2 studies, the control group was either casted or immobilized with a fixator. In the volar plating study, the control group was immobilized by a thermoplastic splint that they were instructed to remove for showering and therefore are not a reliable control group.
  
  The outcome measures used were pain and function (DASH) and/or complications. None of the outcomes were significantly different between early motion and late motion. These data support the recommendation that patients do not need to begin early wrist motion after stable fracture fixation.
• Duration of External Fixation
  In order to limit complications when using external fixation, it is an option to limit the duration of fixation.
  Limited Evidence
  Three prospective studies met the inclusion criteria. These studies, collectively, do not agree upon a length of immobilization and we chose not to define a specific duration. The first study demonstrated no significant difference in groups treated with external fixation for 5 weeks as compared to 3 weeks of external fixation and 2 weeks of additional casting.⁸⁵ The results were reported using a non-validated patient outcome score, hence no clear effect could be demonstrated by the early discontinuation of the external fixation. Two additional studies using a non-validated patient outcome score showed a statistically significant association between outcomes and prolonged external fixation.^{86, 87} Based on limitations of the outcome instruments, the strength of recommendation was graded as “Limited.”
• Amount of Distraction
  We are unable to recommend for or against over-distraction of the wrist when using an external fixator.
  Inconclusive
  Two level II studies met the inclusion criteria. ^{86, 87} There was no statistically significant association between the amount of distraction and patient outcome using a non-validated instrument. However, the work group agreed that the important potential adverse effect of finger stiffness was not evaluated in these studies. It would not be ethical to conduct a prospective study to examine the effect of over-distraction. The work group hence have downgraded the recommendation to “inconclusive”.
• Vitamin C Therapy
  We suggest adjuvant treatment of distal radius fractures with Vitamin C for the prevention of disproportionate pain.
  Moderate Evidence
  We were interested in determining the potential benefit of nutritional supplements in recovery of function after treatment of distal radius fractures. Two studies that met our inclusion criteria examined the use of Vitamin C.^{88, 89} Specifically, the studies found a significant reduction in the incidence of complex regional pain syndrome after treatment of distal radius fracture when the patients were given supplemental Vitamin C. These studies have a serious limitation. The final outcome measure of CRPS is ordinarily difficult to define objectively. The authors used subjective criteria to define pain syndrome in these studies and hence the reliability of the data is limited.  We have hence downgraded the recommendation to “Moderate.”
• Adjuvant Therapy for Rehabilitation
  Ultrasound and/or ice are options for adjuvant treatment of distal radius fractures.
  Limited Evidence
  We included two studies that used non-validated patient outcome measures. The study examining the effect of low-intensity ultrasound reported statistically significant improvement in number of patients with no pain and radiographic union; however no long term or permanent benefit related to a validated outcome measure was demonstrated with the use of low-intensity ultrasound.⁹⁰ The second study demonstrated the value of ice at 3 and 5 days but no benefit for pulsed electromagnetic field therapy (PEMF).⁹¹ The additional cost of ultrasound along with the less reliable evidence resulted in the downgrading of this recommendation to “Limited.”
• Ulnar Styloid Fracture Fixation
  We are unable to recommend for or against fixation of ulnar styloid fractures associated with distal radius fractures.
  Inconclusive
  Ulnar styloid fractures are relatively common in association with distal radius fractures.  We were interested in the effect of concomitant fixation of the styloid on patient outcome.  One study found no difference between treatment (fixation) and no treatment.⁹²  The other study identified ulna styloid fractures after treatment was completed and the study found that there were clinically important differences between patients with and without styloid fractures.⁹³ Therefore no ulna styloid fractures were treated at the time of surgery. Although the patients with ulna styloid fractures had poorer outcomes, the study did not address the question of whether early operative intervention is indicated. Therefore, we found no conclusive evidence to recommend operative or non operative treatment for the ulna styloid fracture.
• Lunate Fossa Depression
  We are unable to recommend for or against using external fixation alone for the management of distal radius fractures where there is depressed lunate fossa or 4-part fracture (sagittal split).
  Inconclusive
  There were no qualified studies identified that addressed this recommendation.