Distal Radius Fracture - Surgical Indications
Initial evaluation for suspected wrist fracture:
- History and Physical Exam
- Radiographs of the wrist AND forearm
Signs and Symptoms concerning for wrist fracture include one or more of the following:
- History of fall or injury onto hand/arm
- Complaints of pain in the wrist or distal forearm
- In the wrist/distal forearm area:
- Tenderness to palpation
- Swelling
- Bruising
- Deformity
- Refusal to use the extremity
Treatment at initial presentation: After a thorough review of the literature regarding surgical indications for distal radial metaphyseal fractures, it was determined that the studies lacked consistent findings for comprehensive comparison and analysis. Thus, the following recommendations are based upon commonly accepted practices within the pediatric orthopaedic surgical community, as defined by synopses in Rockwood & Wilkins (2010) Fractures in Children and the OrthoBullets (n.d.) website and based upon a compilation of published literature. Acceptable alignment is defined below.
- Closed reduction under conscious sedation for patients with fracture displacement.
Proceed to surgical treatment if:
- Inability to be reduced at initial presentation to acceptable alignment
- Neurovascular compromise
- Tight casting required for maintained reduction in setting of concern for compartment syndrome
- Ipsilateral fracture of the distal radius and elbow region
- Displaced complete distal radial fractures
- >10 y/o with angulation > 30* have a re-manipulation rate of 75%
- Bayonette apposition in child > 10 y/o
- Associated ulnar physeal fracture malalignment
- Isolated radial fractures
- Radial and ulnar metaphyseal fractures at the same level
Acceptable alignment is considered on a case-by-case basis depending upon:
- The age of the patient
- Location of the fracture
- Type of deformity:
- Angulation
- Rotation
- Bayonetting
Surgical consideration should be given to patients with radiographic findings outside of the following parameters for Acceptable alignment IN PATIENTS WITH OPEN PHYSIS: Distal radius metaphyseal fracture – acceptable alignment (Orthobullets, n.d.)
|
Sagittal |
Distal Radius/Ulna |
|||
|
Age |
Acceptable Bayonetting |
Acceptable Alignment |
Malrotation |
Dorsal Angulation |
|
<10 y/o |
<1cm |
15-20* |
45* |
30* |
|
>10 y/o |
none |
10* |
30* |
20* |
Distal radius metaphyseal fracture – acceptable alignment (Rockwood & Wilkins, 2010)
|
Age |
Boys – Sagittal plane |
Girls – Sagittal plane |
Frontal plane |
|
4-9 |
20 |
15 |
15 |
|
9-11 |
15 |
10 |
5 |
|
11-13 |
10 |
10 |
0 |
|
>13 |
5 |
0 |
0 |
References
Rockwood, C. A. (2010). Rockwood and Wilkins' fractures in children (Vol. 3). Lippincott Williams & Wilkins.
Walker, R., Bertsch, M., Orbay, J., Myers, D., Johnson, D., & Lambers, A. (n.d.). Distal radius fractures. Orthobullets. Retrieved February 22, 2022, from https://www.orthobullets.com/trauma/1027/distal-radius-fractures
These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.