Distal Radius Fracture

A 67-year-old, left-hand-dominant, retired female sustained a left distal radius fracture when she tripped in her garden and fell onto her outstretched hand. She underwent closed reduction in the emergency department and was placed into a

short arm cast on the day of injury. Her injury radiographs are shown in Figure 6–24A and B.

 

 

 

Figure 6–24 A–B

 

In addition to analgesic medications, what adjunctive medication should the patient be started on as part of her treatment for this injury?

1. Vitamin E

2. Vitamin C

3. Estrogen replacement

4. Bisphosphonate

 

Discussion

The correct answer is (B). As part of the latest AAOS Clinical Practice Guidelines (CPG), approved in December of 2009, it is suggested that patients with distal radius fractures be treated with adjuvant vitamin C as a preventative therapy aimed at reducing the likelihood of developing a complex regional pain syndrome (CRPS). While the studies cited in the CPG statement are limited, CRPS can be quite debilitating and there is some data showing a decreased frequency of developing CRPS with supplemental daily vitamin C after injury.

At her first follow-up appointment, 1 week after her initial fracture reduction and cast placement, repeat radiographs in clinic show that she has lost both radial height and volar tilt.

Which of the following is known to be a predictor of fracture instability with closed treatment?

1. Age greater than 50

2. Initial dorsal angulation >20 degrees

3. Open fracture

4. Difficulty in obtaining initial reduction

5. Female sex

 

Discussion

The correct answer is (B). Acceptable results with closed reduction are generally accepted as radial inclination of at least 15 degrees on PA view, less than 5 mm of radial length shortening, less than 15 degrees of dorsal radial tilt, or less than 20 degrees of volar tilt, and less than 2 mm of articular step-off. Factors predicting failure of closed reduction and immobilization have been studied many times, and one predictive factor that is referenced often is the amount of initial fracture angulation. Also frequently shown to have significant predictive value is increasing patient age (over 58 to 65 years old depending on the study) and the presence of dorsal comminution.

You decide to treat her fracture surgically with a volar plate after she has failed nonoperative management. Her post-op radiographs are shown in Figure 6–25A and B.

 

 

 

Figure 6–25 A–B

 

Which of the following is not an indication for surgical fixation of distal radius fractures?

1. Postreduction radial shortening >3 mm

2. Intra-articular displacement >2 mm

3. Postreduction dorsal tilt >10 degrees

4. Concomitant ulnar styloid fracture

 

Discussion

The correct answer is (D). Choices A, B, and C are the indications for surgical fixation of distal radius fractures according to the latest CPG. Other relative indications for surgical treatment include predicted or established metaphyseal instability, bilateral fractures, or other impairment of the contralateral extremity.

 

Objectives: Did you learn...?

 

 

Indications for operative management of distal radius fractures? Predictors of loss of reduction in patients with distal radius fractures?