Distal Radius Fracture

Patients present after FOOSH (or fall onto a flexed wrist for Smith) with immediate pain, deformity, and inability to use the affected wrist. The "dinner-fork" deformity is the visible clinical sign of a dorsally displaced Colles fracture. Always document hand dominance, occupation, sport, mechanism (height of fall, comorbidities), and time since injury.

Examination is structured around three domains:

• •Inspection: deformity (dinner-fork, gunstock, swelling, bruising), skin integrity (open fracture; threatened skin), and finger posture
• •Palpation: tenderness at the distal radius, ulnar styloid (often involved); document compartment tightness
• •Neurovascular check: this is mandatory and the commonest area of medicolegal error

- Median nerve: hyperaesthesia or numbness in the median distribution. Acute carpal tunnel syndrome is a recognised complication, particularly in displaced or comminuted fractures - Ulnar and radial nerves: sensation and motor function in their respective territories - Radial pulse, capillary refill, distal perfusion

Assess the elbow and shoulder of the same limb (associated injuries from FOOSH in higher-energy mechanisms). Document any DRUJ instability (piano-key sign).

Acute carpal tunnel syndrome after distal radius fracture is a surgical emergency: progressive median nerve symptoms, tense forearm, or unrelieved pain despite analgesia warrant URGENT decompression. Splint, refer.

Plain radiographs (PA and lateral wrist) are first-line and define the pattern, displacement, and intra-articular involvement.

Key radiographic measurements (BOAST parameters):

• •Volar tilt (lateral view): normally 11 degrees volar. Dorsal tilt over 10 degrees post-reduction is unacceptable
• •Radial inclination (PA view): normally 22 degrees. Loss over 10 degrees is unacceptable
• •Radial height (PA view): normally 11 mm. Shortening over 5 mm is unacceptable
• •Articular step (lateral and PA): any over 1-2 mm at radiocarpal or DRUJ
• •Associated ulnar styloid fracture: presence may indicate TFCC/DRUJ instability but does not itself mandate fixation

CT is indicated for:

• •Complex intra-articular fractures (pre-operative planning)
• •Equivocal articular step-off on plain films
• •Die-punch fractures (lunate facet impaction)
• •Comminuted patterns where fragment morphology guides plate choice

MRI is rarely indicated in the acute setting; reserved for suspected scaphoid co-injury, ligamentous instability assessment, or occult fracture in trauma with normal plain films and persistent symptoms (often paired with NICE NG38 MRI-first pathway for suspected scaphoid).

In fragility fractures (low-energy mechanism in over-50s): DEXA scan and FLS referral per NICE CG146; consider bloods for vitamin D, calcium, and TFTs depending on local pathway.

Management is driven by displacement, articular involvement, age, demand, and stability after reduction (NICE NG38, BOAST, DRAFFT-1/2 trials).

Undisplaced or minimally displaced extra-articular fracture:

• •Below-elbow plaster cast for 4-6 weeks, with weekly clinical review for the first 2-3 weeks (peak risk of secondary displacement)
• •Repeat radiograph at 1, 2, and 6 weeks
• •Simple analgesia, sling for comfort; finger ROM from day 1

Displaced fracture requiring reduction:

• •Manipulation under haematoma block, regional, or general anaesthesia
• •Post-reduction X-ray to verify BOAST parameters
• •If acceptable: cast for 4-6 weeks with repeat radiographs to monitor for re-displacement
• •If unacceptable: surgical fixation

Displaced and unstable fracture (failed reduction or BOAST parameters not met):

• •Volar locking plate ORIF is the default UK operative pathway. DRAFFT-1 (Costa et al., BMJ 2014) showed equivalent functional outcomes between K-wires and volar locking plate at 12 months for dorsally displaced fractures. DRAFFT-2 (Costa et al., BMJ 2022) showed cast management non-inferior to K-wires for older patients with dorsally displaced fractures. UK practice has moved toward volar plate for displaced fractures requiring surgery, and cast for many older patients who would previously have had K-wires
• •K-wire fixation alternative for some unstable extra-articular patterns, especially in younger patients with simpler patterns
• •External fixation: rare in modern UK practice; reserved for highly comminuted, contaminated, or polytrauma patterns
• •Arthroscopic-assisted ORIF: specialist centres for complex articular patterns

Smith and Barton fractures: almost always require ORIF (volar locking plate); inherently unstable.

Fragility fracture (low-energy in over-65s) pathway:

• •Surgical decision-making is more conservative; DRAFFT-2 supports cast for many displaced fractures in this group despite radiographic imperfection
• •Outcome correlates more with hand therapy and function than with radiographic perfection in this group
• •ALWAYS refer to FLS / fragility fracture pathway: DEXA, calcium/vitamin D optimisation, bisphosphonate or alternative bone protection per NICE TA464/TA161
• •VTE risk assessment per NICE NG89 (immobilisation in plaster is a VTE risk)

Open fracture: BOAST open fracture pathway - early IV antibiotics, limited wound handling, urgent orthopaedic input, theatre for washout and definitive fixation. Tetanus prophylaxis as required.

Referral pathway: all displaced or intra-articular fractures to fracture clinic same day or next day. Undisplaced extra-articular fractures and fragility fractures to fracture clinic within 1 week. Acute carpal tunnel, open fracture, or vascular compromise to ED / orthopaedics same day.

Conservative pathway (cast, 4-6 weeks):

• •Weeks 0-1: ice, elevation, finger ROM from day 1; shoulder ROM exercises encouraged; monitor for neurovascular deterioration and cast tightness
• •Weeks 1-6: cast maintained; repeat radiographs at 1, 2, and 6 weeks to monitor for displacement
• •Weeks 6-8: cast removed; commence active wrist ROM under hand therapy; gentle isometric grip strengthening
• •Weeks 8-12: progressive strengthening, dart-thrower's motion training, sport-specific loading
• •Return to ADLs: 6-8 weeks; manual work: 8-12 weeks; contact sport: 12-16 weeks depending on bony union

Post-operative (volar locking plate ORIF):

• •Weeks 0-2: removable splint; finger and shoulder ROM from day 1; gentle active wrist ROM as comfort allows
• •Weeks 2-6: progressive active and active-assisted ROM under hand therapy; gentle isometric grip strengthening
• •Weeks 6-12: progressive resistive strengthening; sport-specific loading once bony union verified
• •Return to office work: 1-2 weeks; manual work: 6-10 weeks; contact sport: 12-16 weeks

Post-operative (K-wire fixation):

• •Weeks 0-4-6: cast with K-wires in situ; finger ROM
• •Weeks 4-6: K-wire removal; commence active wrist ROM
• •Weeks 6-12: progressive ROM and strengthening; full return at 12-16 weeks

Fragility fracture rehabilitation: emphasises functional recovery, balance, falls prevention (NICE NG38 falls assessment, occupational therapy review for home hazards), and adherence to bone protection. Hand therapy referral is standard.

Persistent stiffness, deteriorating ROM, or median nerve symptoms beyond 6-8 weeks should prompt reassessment for malunion, CRPS, or median nerve compression. Around 5-10% of distal radius fractures develop CRPS or post-traumatic carpal tunnel syndrome.

• •NICE NG38 Fractures (non-complex, 2016) - UK foundation framework for distal radius fracture management; manipulation, fixation, and follow-up principles.
• •DRAFFT-1 trial (Costa et al., BMJ 2014) - UK randomised trial: equivalent function at 12 months between K-wires and volar locking plate ORIF for dorsally displaced fractures. Established volar plate as a reasonable UK default.
• •DRAFFT-2 trial (Costa et al., BMJ 2022) - UK randomised trial: cast management non-inferior to K-wire fixation in older adults with dorsally displaced fractures. UK practice has tilted toward cast management for many fragility fractures.
• •BOAST Distal Radial Fractures - UK trauma standard: defines acceptable radiographic parameters (volar tilt, radial inclination, radial height, articular step) for cast management; principles of manipulation and fixation timing.
• •NICE CG146 Osteoporosis: assessing the risk of fragility fracture (with NICE TA464 bisphosphonate alendronate / risedronate; NICE TA161 denosumab) - underpins UK Fracture Liaison Service pathway after fragility fracture.

• •Colles (dorsal angulation), Smith (volar angulation), Barton (intra-articular fracture-dislocation), Chauffeur (radial styloid avulsion). Smith fractures are inherently unstable and almost always need ORIF.
• •BOAST radiographic acceptable parameters after reduction: dorsal tilt no more than 10 degrees, radial inclination loss no more than 10 degrees, radial height shortening no more than 5 mm, articular step under 1-2 mm.
• •DRAFFT-1 (2014) established equivalence between K-wires and volar locking plate; DRAFFT-2 (2022) established non-inferiority of cast vs K-wires in older patients. UK practice now favours cast for many fragility fractures and volar plate when surgery is needed.
• •Acute carpal tunnel syndrome after distal radius fracture is a surgical emergency. Progressive median nerve symptoms or unrelieved pain warrant urgent decompression - it is not a routine post-injury finding.
• •Fragility fracture (low-energy fall in over-50s) triggers the FLS pathway under NICE CG146: DEXA, vitamin D / calcium, bisphosphonate or alternative bone protection. Hand fracture is the canonical "sentinel" fragility fracture.
• •Volar locking plate ORIF is the default UK surgical pathway for displaced distal radius fractures requiring fixation. K-wires are alternative for selected extra-articular patterns; external fixation is now rare.