The decision to cast or surgically treat a distal radius fracture is based on several factors. I always take the time to examine each of these criteria prior to making the decision to proceed with surgery. The algorithm is not entirely straightforward as many of the factors are corresponsive. For this reason an individual approach and plenty of personal experience is critical to arriving at the correct course of action. Of course, always ask your treating surgeon why they have arrived at their treatment decision.
1) Patient Age
In truth there are two type of distal radius fractures. The most common is the osteoporotic fracture - this is primarily seen in older patients (age > 65) although other health factors can contribute to this pattern. The other is a high energy fracture pattern seen with younger patients.
High energy fractures in younger individuals are less likely to do well with conservative treatment and often have penetration into the joint that necessitates fixation
Older patients are at an increased risk with surgical intervention due to poorer healing capacity of the soft tissues
2) Intra-Articular vs. Extra-Articular
Intra-articular vs. extra-articular: Intra-articular fractures involve the cartilage surface of the wrist and often require more precise reduction to maintain joint congruence. These are more likely to be considered for surgical intervention.
3) Displacement and Angulation:
The degree of displacement and angulation of the fracture greatly affect whether the fracture will heal and whether there will be an functional limitations as a result
Fractures with dorsal or volar angulation over 15 degrees often have limitations in range of motion that disrupt patient function.
4) Fracture Stability:
If the fracture continues to displace on serial imaging within the first three weeks this is an obvious indicator of fracture instability and poor outcomes with non-operative management
5) Joint Stability
The two bones of the forearm are held together by strong ligamentous attachments. In the event that these ligaments are disrupted, operative intervention is required to restore stability and prevent the development of osteoarthritis.
5) Functional and Activity Demands:
Dominant hand involvement: Fractures of the dominant hand may have a greater impact on daily activities and may influence the choice of treatment.
Occupation and hobbies: The patient's occupation and recreational activities should be taken into account. Those with physically demanding jobs or active lifestyles may benefit from surgery to regain full function more quickly.
6) Patient Preferences:
In general, operative management of distal radius fractures has a faster and more predictable recovery overall.
Some patients that prioritize their healing schedule
Non-operative management by contrast benefits from
Fractures that already weeks out at the time of initial presentation may be partially healed and very difficult to get accurate fracture reduction. As a general rule, if a fracture is >3 weeks old at the time of presentation this will push me toward preliminary fracture healing to complete in a cast.
Fractures that penetrate the skin (Open fractures) need to be treated immediately to reduce the risk of infection.
Ultimately, the decision to cast or surgically treat a distal radius fracture should be made collaboratively between the patient and surgeon, taking into account all these factors and the unique circumstances of each case. The goal is to optimize the patient's outcome in terms of function, pain relief, and recovery.