Guideline sources The following summarized guidelines for the evaluation and management of distal radius fracture (DRF) are prepared by our editorial team based on guidelines from the Eastern Association for the Surgery of Trauma (EAST/AOTA 2023), the American Academy of Orthopaedic Surgeons (AAOS 2020; 2011), the American College of Radiology (ACR 2019), the British Society for Surgery of the Hand (BSSH/BOA 2018), and the Danish Health Authority (DHA 2016). 1 2 3 4 5 6 Guidelines 1. Diagnostic investigations Diagnostic imaging: As per ACR 2019 guidelines, obtain wrist X-ray as the initial imaging in adult patients with acute blunt or penetrating trauma to the hand or wrist. B Show 6 more Updated evidence: BUCKLED https://web.pathway.md/diseases/recpJq53PXwzoccK2 1/6 6/29/23, 10:19 PM Distal radius fracture Pathway In participants 5-15 years of age who presented to the emergency department with an isolated distal forearm injury, without a clinically visible deformity, in whom further evaluation with imaging was indicated, ultrasonography was noninferior to radiography with respect to PROMIS System score at 4 weeks. Peter J Snelling et al. N Engl J Med. 2023 Jun 1. As per BSSH 2018 guidelines, recognize that there is no demonstrated clear association between any measured radiological parameter and patient-rated outcome. B As per DHA 2016 guidelines: Do not obtain routine preoperative CT. D Consider obtaining supplementary CT if conventional X-ray creates doubt as regards the choice of treatment method. E As per AAOS 2011 guidelines, consider obtaining CT to improve diagnostic accuracy in patients with intra-articular DRFs. C 2. Diagnostic procedures Diagnostic arthroscopy: consider performing arthroscopy to improve diagnostic accuracy for wrist ligament injuries in patients with distal radius intra-articular fractures. C 3. Medical management Pain management: As per EAST 2023 guidelines: Consider administering NSAIDs (such as ketorolac) for pain management in adult patients with a traumatic fracture. C Insufficient evidence to recommend for the preference of selective NSAIDs (COX-2 inhibitors) or nonselective NSAIDs. I As per AAOS 2020 guidelines, consider initiating opioid-sparing and multimodal pain management strategies in patients undergoing treatment for DRFs. E 4. Nonpharmacologic interventions Casting: Insufficient evidence to recommend for or against casting as definitive treatment for unstable fractures that are initially adequately reduced. I Insufficient evidence to recommend for or against immobilization of the elbow in patients treated with cast immobilization. I Splinting: Consider preferring rigid immobilization over removable splints when using a nonoperative treatment for the management of displaced DRFs. C https://web.pathway.md/diseases/recpJq53PXwzoccK2 2/6 6/29/23, 10:19 PM Distal radius fracture Pathway Consider using removable splints in the treatment of patients with minimally displaced DRFs. C Exercise programs: As per AAOS 2020 guidelines, recognize that there is no difference in outcomes between a home exercise program and supervised therapy following treatment of DRFs. B As per BSSH 2018 guidelines, consider advising early mobilization in patients with a stable DRF, with a removable support once pain allows. C As per DHA 2016 guidelines: Do not offer routine rehabilitation supervised by an occupational therapist or a physiotherapist in uncomplicated cases. D Provide guidance and practical instruction concerning self-rehabilitation following distal radial fracture in all patients regardless of the treatment method. E As per AAOS 2011 guidelines, consider offering a home exercise program in patients after DRF. C Show 2 more Adjuvant therapies: As per BSSH 2018 guidelines, do not use vitamin C for the prevention of complex regional pain syndrome in patients with DRFs. D As per AAOS 2011 guidelines: Consider offering ultrasound and/or ice as adjuvant therapy in patients with DRFs. C Consider offering vitamin C as adjuvant therapy for the prevention of disproportionate pain in patients with DRFs. C 5. Therapeutic procedures Closed reduction: Avoid performing manipulation in 65 years old patients with moderately displaced DRFs. D Consider offering nonoperative treatment as a primary treatment for displaced DRF in 65 years old patients. Take other factors, such as pre-injury function, medical comorbidities, and fracture characteristics, into consideration and discuss options with the patient. B 6. Surgical interventions Indications for surgical reduction and fixation: As per AAOS 2020 guidelines: Consider performing surgery to improve radiographic and patient-reported outcomes in non-geriatric patients (< 65 years of age) with fractures with post-reduction radial shortening > 3 mm, dorsal tilt > 10 degrees, or intra-articular displacement or step off > 2 mm. C Recognize that operative treatment compared to nonoperative treatment does not lead to improved long-term patient-reported outcomes in geriatric patients ( 65 years of age). A https://web.pathway.md/diseases/recpJq53PXwzoccK2 3/6 6/29/23, 10:19 PM Distal radius fracture Pathway As per DHA 2016 guidelines, perform surgical treatment of a distal radial fracture in patients of any age if a conventional wrist X-ray examination, following eventual reduction of the fracture, reveals 1 of the following radiological parameters: > 10 degrees of dorsal angulation of the articular surface of the radial in a side view as compared to perpendicular to the longitudinal axis of the radial > 2 mm ulnar variance > 2 mm articular step-off incongruity of the distal radioulnar joint. E Show 3 more As per AAOS 2011 guidelines: Consider performing operative fixation in patients with DRFs with post-reduction radial shortening > 3 mm, dorsal tilt > 10 degrees, or intra-articular displacement or step-off > 2 mm as opposed to cast fixation. C Insufficient evidence to recommend for or against operative management in > 55 years old patients with DRFs. I Anesthesia: consider administering IV regional anesthesia (Bier's block), by a healthcare professional trained in the technique (not necessarily an anesthetist), when reducing dorsally displaced DRFs in adult patients in the emergency department. C Show 2 more Technical considerations for surgery: As per AAOS 2020 guidelines, recognize that there is no significant difference in radiographic or patient-reported outcomes between fixation techniques for complete articular or unstable DRFs, although volar locking plates lead to earlier recovery of function in the short term (3 months). A As per BSSH 2018 guidelines, perform K-wire fixation and casting when surgery is required for dorsally displaced DRFs that can be reduced closed. A Show 2 more Updated evidence: DRAFFT2 In adult patients with a dorsally-displaced distal radius fracture that needed manipulation, K-wire fixation was not superior to cast with respect to Patient Rated Wrist Evaluation score at 12 months. Matthew L Costa et al. BMJ. 2022 Jan 19. As per DHA 2016 guidelines, perform open reduction and internal fixation with a volar angular stable locking plate in patients of any age, if surgery is indicated. Consider performing K-wire osteosynthesis as the primary choice rather than bridging external fixation, if open reduction and internal fixation cannot be performed. E Show 6 more As per AAOS 2011 guidelines, insufficient evidence to recommend for or against: any specific operative method for fixation of DRFs https://web.pathway.md/diseases/recpJq53PXwzoccK2 4/6 6/29/23, 10:19 PM Distal radius fracture Pathway locking plates in > 55 years old patients supplemental bone grafts or substitutes when using locking plates bone graft (autograft or allograft) or bone graft substitutes for the filling of a bone void as an adjunct to other operative treatments concurrent surgical treatment of distal radioulnar joint instability fixation of ulnar styloid fractures associated with DRFs external fixation alone if there is depressed lunate fossa or 4-part fracture (sagittal split). I Show 4 more Arthroscopic assistance: Recognize that there is no difference in outcomes between use of arthroscopic assistance and no arthroscopic assistance in the treatment of patients with DRFs. B Consider obtaining arthroscopic evaluation of the articular surface during operative treatment of patients with intra-articular DRFs. C Nerve decompression: insufficient evidence to recommend for or against performing nerve decompression when nerve dysfunction persists after reduction. I 7. Follow-up and surveillance Follow-up: As per AAOS 2020 guidelines, recognize that there is no difference in outcomes based on frequency of radiographic evaluation in patients treated for DRFs. B As per BSSH 2018 guidelines, consider obtaining careful follow-up after reduction in patients with DRFs displaced on the initial films, as they are at increased risk of subsequent re- displacement. C Show 2 more As per AAOS 2011 guidelines, consider obtaining a post-reduction true lateral X-ray of the carpus to assess distal radioulnar joint alignment in all patients with DRFs. C Show 2 more Clinical findings Symptoms Past medical history Wrist pain Osteoporosis Wrist swelling Social history Past events Sports participation Falls Motor vehicle accident Musculoskeletal exam https://web.pathway.md/diseases/recpJq53PXwzoccK2 5/6 6/29/23, 10:19 PM Distal radius fracture Pathway Wrist deformity Wrist tenderness Studies 2023 BUCKLED In participants 5-15 years of age who presented to the emergency department with an isolated distal forearm injury, without a clinically visible deformity, in whom further evaluation with imaging was indicated, ultrasonography was noninferior to radiography with respect to PROMIS System score at 4 weeks. Peter J Snelling et al. N Engl J Med. 2023 Jun 1. 2022 DRAFFT2 In adult patients with a dorsally-displaced distal radius fracture that needed manipulation, K-wire fixation was not superior to cast with respect to Patient Rated Wrist Evaluation score at 12 months. Matthew L Costa et al. BMJ. 2022 Jan 19. References 1. American Academy of Orthopaedic Surgeons. Management of Distal Radius Fractures: Evidence- Based Clinical Practice Guideline. AAOS. 2020 Dec 5. Open 2. Charles Pailthorpe, Joe Dias, Adam Brooks et al. Best practice for management of Distal Radial Fractures DRFs). BSSH. 2018. Open 3. David M Lichtman, Randipsingh R Bindra, Martin I Boyer et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: the treatment of distal radius fractures. J Bone Joint Surg Am. 2011 Apr 20;93 8 775 8. Open 4. Danish Health Authority. National Clinical Guidelines on the Treatment of Distal Radial Fractures. Sundhedsstyrelsen. 2016 Jan. Open 5. Patrick B Murphy, George Kasotakis, Elliott R Haut et al. Efficacy and safety of non-steroidal anti- inflammatory drugs NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association. Trauma Surg Acute Care Open. 2023 Feb 21;8 1):e001056. Open 6. Expert Panel on Musculoskeletal Imaging:, Maha Torabi, Leon Lenchik et al. ACR Appropriateness Criteria Acute Hand and Wrist Trauma. J Am Coll Radiol. 2019 May;16 5S S7 S17. Open https://web.pathway.md/diseases/recpJq53PXwzoccK2 6/6