The overarching goal in the treatment of patients with distal radius fractures is to help the patient have a painless, stable wrist that is functional; that is, allowing return to normal activities within a physiologic range of motion. Stability evaluation includes assessment of potential radiocarpal dislocation or distal radioulnar joint instability that may require additional treatment.²,³ Standard AO principles are used as the surgical tactic: (1) fracture reduction to restore anatomic relationships; (2) fracture fixation providing absolute or relative
stability, depending on the type of fracture, patient, or injury; (3) preservation of blood supply (soft tissues and bone); and (4) early and safe mobilization.

General indications for surgical intervention include unacceptable radiographic fracture alignment (shortening greater than 5 mm, radial inclination less than 15°, dorsal angulation greater than 10° or volar angulation greater than 25°, articular step-off greater than 2 mm, disruption of the lateral radiocarpal alignment), volar or dorsal radiocarpal instability, or distal radioulnar joint instability.⁴ However, there continues to be considerable debate about surgical versus nonsurgical management of distal radius fractures, especially in lower demand older age patients. Two recent studies found that clinical, radiographic, and patient-reported outcome measures in younger patients were better with surgical fixation compared with nonsurgical management in well-reduced distal radius fractures at 1-year follow-up.⁵,⁶ Even in the elderly population, two subsequent randomized controlled trials found that although outcomes were similar at 1-year follow-up, patients who underwent surgical treatment had faster recoveries, were more satisfied with their function, and had similar rates of complications.⁷,⁸ Concurrently, a large retrospective database study conducted in 2019 found that comorbidities were more strongly associated with developing complications than patient age.⁹ In total, these findings highlight the importance of individualized patient care.

There are a variety of options to treat patients with distal radius fractures. Closed reduction and casting are indicated for fractures that are stable with minimal metaphyseal comminution, shortening, angulation, or displacement. Close weekly follow-up is required to evaluate for secondary displacement over 2 to 3 weeks while swelling subsides. Closed reduction and percutaneous pinning (typically with Kirschner wires [K-wires]) is indicated for simple intra-articular or extra-articular fractures with mild comminution and no osteoporosis, or for fractures in children with open growth plates.
External fixation can be used in highly comminuted fractures that are more difficult to fix rigidly, especially when soft-tissue contamination is present. Open reduction and internal fixation is typically indicated for unstable distal radius fractures. Multiple variations of open reduction and internal fixation have been described, including a volar plate through a volar approach, dorsal plate through dorsal approach, fragment-specific fixation, or a dorsal spanning plate. Fragment-specific fixation refers to a treatment approach for complex articular fractures characterized by independent fixation of each major fracture component with an implant specific for that fragment based on its size and location.¹ Recent studies have highlighted the value of advanced imaging in the characterization of dorsal articular fragments to aid with preoperative planning in terms of surgical approach, fixation strategy, and intraoperative evaluation.³,¹⁰ Specifically, one article described the location of injury in a series of 13 patients with dorsal Barton fracture-dislocations, whereas another article characterized the morphology and size of the dorsal ulnar corner fragment. The use of dorsal spanning plates for fixation of distal radius fractures is versatile, and typical indications include metadiaphyseal comminution of the radius, the need for weight bearing through the upper extremity, polytrauma, augmented fixation, carpal instability, or salvage of prior failed treatment.¹¹ In terms of fixation method, the Wrist and Radius Injury Surgical Trial randomized 187 patients to internal fixation, external fixation, or percutaneous pinning compared with 117 patients who preferred nonsurgical treatment. Although recovery was fastest for internal fixation, by 12 months there was no meaningful difference in outcome.² Similar findings also were reported in a network meta-analysis comparing outcomes after treatment of distal radius fractures in adults using external fixation, intramedullary nailing, K-wires, casting, or plate fixation.¹²

Increasingly, hybrid and arthroscopic-assisted approaches are being used. Arthroscopy can be a helpful adjunct to diagnose concomitant carpal ligament or triangular fibrocartilage complex injuries, or to facilitate anatomic reduction of the joint surface.¹³ Arthroscopic assistance is especially helpful in radial styloid and diepunch fracture patterns where percutaneously placed K-wires can be manipulated under arthroscopic visualization to reduce and stabilize articular fragments. These K-wires can then be replaced with percutaneously placed cannulated screws, or the K-wires can be kept in place to support the subchondral area of the distal radius to maintain the articular reduction in combination with a volar or dorsal plate. Regardless of treatment approach, recent studies have highlighted the role for dorsal tangential fluoroscopic views and assessment of carpal alignment in relation to the volar cortex of the distal radius to evaluate dorsal screw penetration, fixation placement, and fracture reduction.⁴,¹⁴

The primary goal of treatment of patients with scaphoid fracture is to facilitate healing of the fracture to allow the patient to have a painless, stable wrist that is functional, allowing for return to normal activities with physiologic range of motion. In terms of surgery, this equates to the attainment of an anatomic reduction with stable rigid fixation, except in cases of distal pole nonunion, where excision of the distal pole nonunion fragment may allow for the patient to have a painless, stable functional wrist.

Scaphoid fractures can be managed via a percutaneous or open approach. Indications for percutaneous fixation include nondisplaced scaphoid waist fractures, displaced scaphoid waist fractures that can be closed reduced, and nondisplaced proximal pole fractures. Volar and/or dorsal open approaches can be used to facilitate fracture reduction and fixation based on fracture characteristics and surgeon preference. Arthroscopy is increasingly used to aid with percutaneous fracture reduction, bone grafting, and fixation.²⁴

Common fixation strategies include K-wires, headless compression screws, and plates. Headless compression screws may be inserted along the central axis of the scaphoid or perpendicular to the fracture plane within the middle third of the scaphoid based on fracture anatomy and surgeon preference. A 2020 retrospective cohort study comparing clinical and radiographic outcomes between K-wire and cannulated compression screw fixation in the management of scaphoid nonunions found no difference in bony healing or functional outcomes at the time of final follow-up.²⁵ Plate fixation of scaphoid fractures is relatively more recent and typically indicated in settings of significant comminution or segmental bone loss that is managed with bone grafting. Union rates between plate fixation and cannulated compression screws are similar, although the rate of hardware removal was higher for the plate fixation group.²⁶

Bone graft is typically used in the management of scaphoid nonunions. Bone grafts can be divided based on two characteristics: (1) structural versus nonstructural, and (2) vascularized versus nonvascularized. Structural bone graft is typically used in the correction of humpback deformity or segmental defects within the scaphoid, but there is significantly more debate regarding the need for vascularized versus nonvascularized bone graft. Common sources for nonvascularized graft include the distal radius and iliac crest. Vascularized bone grafts are either pedicled (eg, 1,2-intercompartmental supraretinacular artery) or free (eg, medial femoral condyle/medial femoral trochlea [MFT]). A 2019 retrospective cohort study of 109 patients compared the use of structural iliac crest, 1,2-intercompartmental supraretinacular artery, and MFT bone grafts to manage scaphoid nonunions. Union rates and mean time to union were similar for all three groups.²⁷ Another study reported 35 consecutive scaphoid nonunions managed with nonvascularized bone grafting and demonstrated healing in 33 of 35 patients by 12 weeks.²⁸ In addition, a 2020 national database study comparing rates of revision surgery after management of scaphoid nonunions using vascularized versus nonvascularized bone grafts found similar rates of revision surgery, suggesting that nonvascularized bone grafting may be a reasonable first option.²⁹ These results highlight the value of careful patient selection when deciding on the type of bone graft to use.

Proximal pole reconstruction after scaphoid nonunion has historically been a challenging problem to manage. Recent literature has highlighted the utility of two new bone grafts: the proximal hamate nonvascularized bone graft and the MFT osteochondral free flap. A
2019 case study illustrated the use of the proximal pole of the hamate as a replacement arthroplasty in settings where the proximal pole scaphoid nonunion has undergone collapse with bone loss and/or osteonecrosis.³⁰ A subsequent 2020 morphologic study demonstrated the proximal hamate was a good fit for the proximal scaphoid in most of the cases.³¹ A separate case series of 11 patients with 2-year follow-up after MFT osteochondral free flap reconstruction for the scaphoid proximal pole demonstrated radiographic union with improvement in functional and patient-reported outcomes in all patients.³²