Restoration of the volar cortex: predicting instability after manipulation of distal radial fractures

Distal radial fractures are one of the most common fractures that are presented to the emergency department (ed). The management of non-emergent cases often involves closed reduction and immobilisation before referral to orthopaedic services. Surgical intervention is offered based on the criteria for instability. This can be predicted from the initial and post-manipulation radiographs. The purpose of this study was to assess the role of various predictors of instability in the requirement for surgery, based on specific evidence-based criteria.

We audited 87 consecutive distal radial fractures that had been manipulated by the ED and analysed what factors predicted instability.

The most significant predictor of instability and hence further surgery was the failure to anatomically restore the volar cortex (VC) (p = 0.002) during the manipulation. Other significant factors were increasing age (p = 0.006) and fracture of the ulna styloid (p = 0.028). If the VC was restored or remained intact during the manipulation, only 38% required further surgery. If the VC was displaced or not restored, 65% required further surgery.

The restoration or maintenance of volar cortical alignment during the manipulation of distal radial fractures offers patients the best chance of avoiding the need for further surgery. This factor should be taken into account in the decision-making process for these fractures.