Closed manipulation and casting of distal radius fractures

Closed reduction and cast treatment of distal radius fractures renders satisfactory results in fractures that are reducible and stable and do not re-displace in plaster in the first 2 weeks following reduction. Intra-articular and unstable fractures have a high risk for re-displacement in plaster and therefore represent a contraindication for cast treatment. A fracture that re-displaces in plaster despite perfect casting technique is most probably an unstable type that requires skeletal fixation. A fracture that re-displaces in a non-molded, loose, or over-padded cast because of insufficient technique is, however, in the author's view, the only clinical situation in which re-manipulation is worth the effort. The tolerable amount of residual deformity has been radiographically defined by Fourrier et al in an analysis of 64 malunions of the distal radius and correlated the functional impairment with the residual deformity of the distal radius. They concluded that the lower limits of deformity, at which symptoms are likely to be present, area radial deviation of 20-30 degrees, a sagittal tilt of 10-20 degrees, and a radial shortening of 0-2 mm. In addition, experimental evidence suggests that a sagittal tilt of 20-30 degrees should be viewed as a pre-arthrotic condition. Although these figures are useful for decision making, acceptance of deformity when treating fractures conservatively varies individually according to the age, osteoporosis, and functional demands of the patient. Anatomic restoration, however, should remain the primary goal of conservative management.