Nonoperative Treatment of Distal Radius Fractures

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CHAPTER 2 Nonoperative Treatment of Distal Radius Fractures

Joseph J. Dias, MD, FRCS, FRCS (Edin), MBBS

Indications

The fractures of the distal radius best suited for nonoperative treatment are (1) undisplaced and minimally displaced stable fractures, (2) bending fractures in good bone, and (3) intra-articular fractures where there is almost no step between the intra-articular fragments.

Radiographic Criteria for Nonoperative Treatment

On the assumption that the wrist was normal prior to the fracture of the distal radius my colleagues and I recommend the following radiographic criteria for nonoperative treatment after reduction if required: dorsal tilt of the distal radius articular surface of less than 10 degrees, intra-articular step of less than 1 mm, and 3 mm of ulnar variance. In very osteoporotic individuals or those who are unwell or physiologically elderly, however, we may accept up to 20 degrees of dorsal tilt, an intra-articular step of 2 mm, and 5 mm of ulnar-positive variance.

Undisplaced and Minimally Displaced Fractures

It is usual to treat undisplaced or minimally displaced stable fractures of the distal radius in a below-elbow plaster of Paris cast for 4 to 6 weeks. The wrist is usually immobilized in slight extension so as to allow some activities of daily living. Even in undisplaced fractures, the cast is applied with some molding to reduce the risk of loss of position of the fracture during bone healing.

The cast is made up of an 8-inch plaster of Paris slab extending from the distal palmar crease around the radial aspect of the wrist and proximally up to the proximal third of the forearm. A hole is cut out for the thumb. The pronated forearm is held by two assistants, one holding the arm just above the elbow and the other holding the extended fingers. These assistants must give slight traction along the line of the forearm (Fig. 2-1). The hand and forearm are covered firmly with synthetic wool, and the plaster slab is applied to extend around the radial side of the forearm and wrist and ulnarward both dorsally and on the palmar side. This slab is then firmly bandaged in place with a crepe bandage. As the plaster sets it is molded with three points of compression to counter the dorsal bending deformity of the distal radius fracture. The palmar point of compression overlies the site of the fracture and forms the fulcrum over which the dorsal two compression points stretch the broken bone, thereby countering the dorsal bending tendency of such a fracture (Figs. 2-2 and 2-3).

FIGURE 2-1 Traction of the Hand. The patient is supine with the shoulder abducted, the elbow flexed to a right angle, and the forearm pronated. One assistant holds the arm and provides countertraction as the other pulls on the index and middle fingers.

FIGURE 2-2 The precise position of the physician’s hands in order to mold the fracture into its proper alignment is demonstrated. The physician is positioned facing the patient’s head. The physician’s hand near the patient is used to provide the fulcrum for the molding and lies close to the fracture but proximal to it. The physician’s hand away from the patient is used to mold the fracture by pressing the thenar eminence over the distal fragment of the fracture. This should stretch the probably intact dorsal periosteum and reduce the fracture, provided that the palmar cortex at the site of the fracture is not comminuted.

FIGURE 2-3 The below-elbow plaster of Paris slab is demonstrated with the smooth molds apparent.

The cast is a radially based gutter slab encompassing four fifths of the circumference of the forearm. This leaves the ulnar side of the forearm free to accommodate for any immediate swelling. The bandaging can be tightened in the first 2 weeks as the swelling reduces. Alternatively the cast can be reapplied. The distal extent of the plaster of Paris slab extends to the distal palmar crease on the ulnar side and the proximal palmar crease on the radial side to allow full flexion of the metacarpophalangeal joints over the distal palmar edge of the cast.

In the initial day or two after reduction, patients are advised to clench and unclench the hand on the affected side and to elevate the hand on pillows when at home. Attention must be paid not to flex the elbow above a right angle to avoid circulatory compromise and stretching of the ulnar nerve. The patients are encouraged to use the hand for light activities of daily living and are told how to avoid getting the plaster wet when bathing. They are encouraged to return to the clinic if they experience any problems or if the plaster of Paris slab breaks or becomes soft. Patients are also provided with written instructions on care of the plastered extremity.

Do Undisplaced Fractures Need Immobilization?

Undisplaced or minimally displaced fractures can be safely treated in a plaster of Paris slab. Stable fractures can also be safely treated without immobilization. In a prospective randomized study of 97 fractures, Dias and associates ¹ demonstrated that the treatment of such fractures without a cast did not result in greater displacement or more discomfort than those treated in a cast. Moreover, more patients treated without immobilization recovered grip and movement within 8 weeks compared to those immobilized in a cast.

Displaced Fractures

Extra-articular Fractures

Extra-articular displaced fractures need to be carefully manipulated back into place. The technique described by Charnley ² needs to be followed to disimpact the fracture by giving traction. Traction may be easily given using manual distraction or alternatively may be provided by finger traps and weights as described by Earnshaw and coworkers.³ Once the fracture has been disimpacted, the wrist can be manipulated in pronation to counter the tendency of the distal fragment to supinate. Although flexion of the wrist has been suggested to counter the dorsal angulation of the distal radius, the fracture can be gently manipulated to correct the dorsal tilt by molding. The physician stands facing the patient’s head, on the thumb side of the pronated forearm. The physician’s hand nearest the patient supports the palmar side of the radius just proximal to the fracture. The physician’s hand away from the patient is used to push down on the dorsum of the distal fragment (see Fig. 2-2). The fracture is then assessed under fluoroscopy. If the position is satisfactory, especially with the traction released, a plaster slab is applied as described above.