A thorough history and physical examination is essential with particular attention focused on the soft-tissue integrity and neurocirculatory examination of the extremity. The brachial, radial, and ulnar pulses should be palpated and/or dopplered. A careful neurologic exam of the extremity should assess the motor and sensory integrity of the radial, median, and ulnar nerves. This must be clearly documented. The skin should be inspected for the presence of open wounds including small wounds on the ulnar side of the wrist. Furthermore, the forearm and elbow should be checked for swelling and tenderness to rule out an associated Galeazzi, Monteggia, or an Essex-Lopresti injury. The forearm musculature should be palpated to rule out a frank or evolving compartment syndrome. The hand should also be examined for pain or deformity, which might indicate a combined injury such as a carpal or metacarpal fracture or dislocation. Patient-specific information, hand dominance, occupational requirements, medical comorbidities, and expectations often guide treatment recommendations. Once the physical examination has been completed, a closed reduction of the fracture and a sugar-tong or long-arm splint should be applied. The wrist should not be placed in a “hyper-flexed” posture that might increase pressure in the carpal canal. Any signs or symptoms of increasing pain or paresthesias mandate that any splints or cast be loosened or removed for a more precise evaluation and treatment. Osteoarthritic fingers are especially vulnerable to postfracture swelling and pain. Acute tendon injuries are rare following closed distal radius fractures.

High-quality anteroposterior (AP) and lateral radiographs of the wrist and entire forearm must be obtained. In some cases, comparative contralateral wrist films are helpful. Postreduction radiographs often clarify the fracture pattern and help determine fracture stability. In comminuted or complex fracture patterns, CT scans with axial, coronal, and sagittal reconstructions can be useful to better clarify the fracture pattern and morphology. CT scans should only be obtained after the fracture has been reduced and splinted. Scans done with the fracture shortened, displaced, and angulated rarely provide useful information and waste health care resources. For selected unstable fractures, fluoroscopic traction views can also provide useful information about facet displacement and may determine or alter the surgical approach. Traction films can also reveal subtle, combined, carpal bone, and/or ligamentous injury.

Unstable closed fractures of the distal radius without neurovascular compromise require timely but thoughtful intervention. Surgery should be scheduled semielectively following reduction and splinting. Open fractures, on the other hand, require urgent irrigation, débridement, and stabilization. All patients with compartment syndromes or acute carpal tunnel syndrome require emergent decompression.

In a subset of patients following closed reduction, there is redisplacement on follow-up radiographs. Patients treated nonoperatively should be followed weekly for 21 days to monitor this potential redisplacement. We caution against a “slippery slope” phenomenon whereby a small amount of displacement is accepted at 1 week and a bit more at 2 weeks followed by a grossly unacceptable reduction at 3 or 4 weeks. If there is more than 2 to 3 mm of displacement on follow-up radiographs, surgery is recommended.

The definitive treatment plan is based upon fracture stability, patient expectations, functional requirements, and medical comorbidities. Significant alterations in radial length, radial inclination, and reversal of palmar tilt have been correlated with less favorable results. These outcomes are worsened with articular incongruity and carpal subluxation (4, 5 and 6). However, mild or even moderate degrees of deformity do not preclude a satisfactory result, increasing the importance of individualizing treatment. All patients with a displaced distal radius fracture should have a closed reduction and application of a sugar-tong splint or split long-arm cast. We use either an intravenous Bier block or a fracture hematoma injection. If a hematoma block is used, it is important to also inject the ulnocarpal joint to improve patient comfort when there is an ulnar styloid fracture or concomitant ligament injury. Unstable fractures are treated with surgery. In most cases, it is better to perform primary osteosynthesis rather than corrective osteotomy.

Unstable distal radius fractures should not be treated with joint-spanning external fixation alone (Fig. 13.1). Outcomes are improved with adjunctive techniques such as Kapandji dorsal intrafocal pinning, transradial styloid-intramedullary pinning, and metaphyseal grafting with allograft or calcium phosphate bone cement (10,11) (Fig. 13.2). In minimally comminuted fractures, with sufficient distal fragment bone stock, nonspanning external fixation may be preferable, as it allows better control in restoring radial length, inclination, and palmar tilt (12). Dorsal or volar shear fractures, such as Smith’s and dorsal or volar Barton’s, should be treated with a locked buttress plate. Occasionally, in highly comminuted fractures, a bridging frame is used as an adjunct to an open reduction and internal fixation (Fig. 13.3). This can be helpful with the small volar or dorsal pericapsular shear fractures associated with carpal instability. Scaphoid or lunate die-punch injuries should be treated with elevation of fragments and subchondral bone grafting stabilized with K-wire fixation. This can be performed with arthroscopic assistance or via fluoroscopic guidance (10) (Fig. 13.4).