5.1.1 Why Surgery Is Not Usually Needed

Surgery might be fun, fulfilling, exciting, and lucrative but it is also expensive, time-consuming, and potentially dangerous. We should remember that the great majority of distal radius fractures (DRFs) do not need surgical treatment. New techniques do not necessarily offer an advantage. We should always resist the temptation to perform surgery that will probably not improve patients’ outcomes or that would put them at unnecessary risk of harm. The evidence for surgery is by no means as compelling as some proponents might imagine. ¹ Indeed, the distal radius seems biologically designed to survive injury. ²

There is scant evidence that radiology correlates strongly with outcome and most fractures will fare perfectly well even if they heal with modest displacement. ^{3 , 4 , 5 , 6} Furthermore, even after surgery, function does not seem to correlate well with the radiographic appearance. ⁷ Several studies show that fractures with modest displacement (intra- or extra-articular) do not predispose to symptomatic arthritis, ^{8 , 9 , 10 , 11 , 12} and there is consistent evidence that surgery for those over 65 does not influence outcome. ^{1 , 13 , 14 , 15} Surgery is expensive, particularly with modern implants, ¹⁶ and of course hazardous; any operation can harm patients and make them worse than nonoperative care. ^{17 , 18 , 19}

5.1.2 Nonoperative Treatment Is Usually Effective

An undisplaced stable crack through the distal radius will heal uneventfully with just 3 weeks in a cast. ^{20 , 21}

For a displaced fracture, manipulation under a local or regional anesthesia and then plaster are usually adequate; X-rays should be taken at the end of the first and second week to ensure that it has not slipped. If particularly unstable, X-rays into the third week are justified. ^{22 , 23} If the fracture does slip, gentle manipulation and replaster will suffice for many.

5.1.3 Surgery Carries Risk

Anesthetic complications are exceedingly unusual. Risks include an allergy to local anesthesia, neurological damage with an axillary block, and a cardiovascular event with a general anesthetic.

Volar plate fixation has a material risk. In a systematic review of 33 articles and 1,817 cases, Bentohami et al found a 16.5% complication rate: 8.8% minor (e.g., superficial infection, complex regional pain syndrome (CRPS), tendon irritation, and neuritis) and 7.7% major (e.g., hardware failure, deep infection, and tendon rupture). ¹⁷ Kirschner wires (K-wires) are even more hazardous than plates with 26 to 28% suffering a complication, including pin track infection, carpal tunnel syndrome due to fragment migration, and corrective osteotomy for malunion. ^{24 , 25} In a literature review, Diaz-Garcia et al found complications requiring surgery in 11% of those having volar plates and 1% in those having a plaster cast. ¹⁴

5.1.4 Risks of Nonoperative Intervention

The patient and surgeon must also be aware that nonoperative care is not without risk. ²⁶ Risks include:

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  Tight plaster cast—predisposes to CRPS. ^{27 , 28}

  
  
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  Poor fitting cast to include metacarpophalangeal (MP) joint—MP contracture.

  
  
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  Excessive flexion—carpal tunnel syndrome.

  
  
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  Loss of position and thus an avoidable unsatisfactory outcome.

  
  
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  Losing opportunity for early simple fixation, requiring later complex osteotomy and fixation.

  
  
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  Extensor pollicis longus rupture.

5.2.1 Drawbacks of the Literature

The recommendations or guidelines for treatment are inconsistent. This reflects the conflict between surgical experience and insufficient literature. Randomized trials are rarely translatable to clinical practice because of marked heterogeneity, exclusion criteria, and debatable outcome measures. Hence, apparently compelling studies comparing wires and plates ²⁹ can be reasonably criticized. ³⁰

Furthermore, guidelines tend to be based on simple parameters of dorsal tilt and ulnar shortening; they do not capture more subtle but probably equally important measurements such as radial, dorsal, and palmar translation.

5.2.2 Authors’ Recommendations

Some authors propose their own guidelines for surgery. See ▶Table 5.1.

5.2.3 Consensus Review

Many authors and professional bodies have produced recommendations on indications for surgery. For example, the Danish Health and Medicines Authority and the American Academy of Orthopaedic Surgeons (AAOS) have produced clinical practice guidelines after a thorough literature review and expert panel consensus (▶Table 5.1 ). ^{31 , 32} What is notable is the lack of consensus on the parameters for which surgery is indicated. The AAOS were only able to recommend their recommendations with “moderate” strength (▶Table 5.1 ) due to a lack of compelling strong evidence ³² ; others, including Green’s textbook and the British Orthopaedic Association, decline to make specific recommendations for parameters indicating surgery, instead advising clinical discretion upon consideration of the individual patient and factors influencing fracture stability. ^{33 , 34}

5.3.1 Older Age

Age is an important consideration. As patients get older, they have lower demands and therefore tolerate malunion better. They are also at higher risk of fixation failure due to osteoporosis. The AAOS practice guidelines could not conclusively recommend surgery for those over 55. ³² Researchers consistently fail to find benefit for operating on those over 60 or 65 with regards to functional outcome regardless of radiological anatomy. ^{6 , 14 , 37}

5.3.2 Younger Age

Those of a younger age with higher demands might be more aware of the physiological consequences of altered radiological anatomy. Gliatis et al suggest that function (measured with the patient evaluation measure) is less likely to be acceptable with a dorsal angulation of >10° in younger patients (median age 35, all below 49) ³⁸ ; Grewal and MacDermid found that there was a correlation between radiological position and outcome following extra-articular DRFs, but the strength of that correlation decreased with age and was not measurable over the age of 65. ¹³ These authors found that over the age of 65, 8 patients with malaligned fractures (malalignment defined as dorsal angulation >10°, radial inclination <15°, or positive ulnar variance ≥3 mm) would need corrective surgery to avoid one bad outcome (defined by poor disabilities of the arm, shoulder, and hand [DASH] score), whereas under the age of 65, only two patients would need surgery for one to benefit. ¹³

5.4.1 Exclusion Bias

As discussed above, the literature cannot be readily applied to an individual patient. Finsen and colleagues found in a series of 260 patients treated nonoperatively that although function correlated with anatomy, the magnitude was very small with only 11% of the variability in outcome being explained by the combination of ulnar variance, dorsal angulation, and radial inclination. ⁵ However, this series, as in other nonoperative series, will not include those in whom the surgeon has detected other variables such as high demand, intra-articular displacement, propensity to slip, marked displacement or joint subluxation such that these have been treated surgically and thus excluded from the apparently favorable outcome. The same argument can apply to randomized trials comparing wires, plasters, or plates.

5.4.2 Distal Radioulnar Joint Incongruity

Volar tilt or dorsal tilt will alter congruity of the distal radioulnar joint (DRUJ). It is difficult to predict the threshold of tilt at which fractures will lose rotation if left untreated because different patients are likely to be affected differently, depending on the relative concavity or flatness of the sigmoid notch. Nevertheless, abnormal volar or dorsal tilt will affect rotation. ^{39 , 40}

Rotation will also be affected by radial translation of the distal radius ⁴¹ as well as by dorsal/palmar translation. These parameters are not captured in the usual radiological functional studies discussed above. While computed tomography scans are not routinely performed, obvious incongruity on the transverse images would be a prompt to surgical reduction.

In clinical practice, it is commonly observed that loss of rotation with a malunited DRF will cause substantial disability and will usually respond well to corrective osteotomy of the radius. As the tilt is corrected, rotation returns (unless there is secondary capsular contracture, which may also need releasing).