By Kostas P. Panagiotopoulos, MD, FRese, Vancouver, Be
Originally printed in the COA Bulletin #71, November/December 2005. Reprinted with kind permission.

Distal radius fractures are among the most common injuries seen by the orthopaedic surgeon. In order to manage these injuries with closed reduction and casting, the fractures must be reducible with closed manipulation and they must remain stable until healing occurs. The indications and success of closed manipulation and casting are dependent on many factors. These include patient age, bone quality, occupation, associated injuries, degree of initial
displacement, cancellous impaction and cortical comminution. In general, nonoperative treatment is recommended for
undisplaced extra- and intra-articular fractures for stable, displaced fractures, and certain unstable fractures in elderly,
lower-demand individuals where some secondary displacement is acceptable (Fernandez, 2005).

There is a strong correlation between the initial radiographs and success of closed manipulation and casting. Fractures are considered unstable if the initial radiographs show 200 or more dorsal (or volar) angulation, displacement of more than two-thirds width of the shaft, metaphyseal comminution, more than five rnillimetres of shortening, intra-articular extension, associated ulnar fracture or advanced osteoporosis. If three or more risk factors are present, there is a higher likelihood of fracture collapse (Lafontaine, Delince, Hardy, & Simons, 1989). In these cases, the treating physician may consider surgical intervention on immediate presentation. Other studies have shown that radial shortening is a very reliable indicator of future shortening (Altissirni, Mancini, Azzara, & Ciaffoloni, 1994; Hove, Solheim,
Skjeie, & Sorensen, 1994). In addition, older patients seem to be at higher risk for future displacement given the poor bone quality (Leone, Bhandari, Adili, McKenzie, Moro & Dunlop, 2004; Nesbitt, Failla, & Les, 2004).

In most instances, the decision to proceed to operative intervention is made after looking at the initial radiographs.
Despite the plan for operative treatment, it is still prudent to attempt a closed reduction in order to improve patient comfort, restore anatomy for surgical planning and relieve pressure on any neurologic structures.

In order to carry out closed manipulation, adequate analgesia is required. Hematoma blocks, intravenou regional sedation, brachial plexus block and general anesthesia are all reliable methods. In most cases, a hematoma block or intravenous regional sedation is adequate. Some authors recommend injection solution through the volar cortex in addition to infiltrating the distal radioulnar joint and ulnar styloid fracture in order to provide complete analgesia. Regional blocks are indicated in cases where a difficult reduction is anticipated. General anesthesia is indicated for special circumstances such as paediatric fractures (Fernandez, 2005).