An evidence synthesis of the distal radius fracture for FESSH candidates and consultant peers — the epidemiology that makes it a sentinel fracture, the radiographic parameters and classifications and how little they agree, the prediction of instability, the randomised trials of casting, wiring and plating at every age, the complications of the volar plate, the distal radioulnar joint, complex regional pain syndrome and vitamin C, rehabilitation, and what the guidelines say.
The distal radius fracture is one of the commonest fractures in orthopaedic and hand surgical practice1, and one on which large pragmatic trials have changed practice2. The spread with little randomised support3; DRAFFT then moved practice in England back towards Kirschner wires42, and DRAFFT2 and a series of trials in older patients strengthened the case for casting many fractures53. The questions an examiner asks follow that history: which fracture is unstable, how much deformity matters at what age, what the trials actually compared, and what goes wrong after fixation.
This article covers epidemiology and bone health, imaging and the radiographic parameters, classification and its reliability, instability, acceptable alignment and age, non-operative and operative treatment, the complications of plating, the and ulnar styloid, and vitamin C, malunion, rehabilitation and the guidelines. It ends with points that recur in examinations.

§ 01 · EPIDEMIOLOGY AND THE FRAGILITY SIGNAL

Incidence

In the UK Colles' Fracture Study, the age-adjusted incidence of distal forearm fracture in people aged 35 and over was 36.8 per 10,000 person-years in women and 9.0 in men; in women it rose progressively from the perimenopausal period, whereas in men it stayed low until later life6. The guideline summary of the American Academy of Orthopaedic Surgeons () and the describes a bimodal distribution, with peaks in the young and in people over 65, and states that incidence continues to rise in all age groups7. Population data elsewhere point the other way in older adults: in southern Sweden the incidence in 2016 was 22 per 10,000 — 34 in women and 10 in men — and 0.76 of the 2001 figure, a fall driven by people aged 50 or older8; in a Japanese region the age-adjusted incidence in women fell significantly between 2011 and 2020, with peaks at 10–14 years in males and 75–79 years in females9. In the same Japanese series, AO/OTA types A, B and C made up 78.7, 1.7 and 19.6 per cent of fractures in patients over 159. Among 4,463 adults attending one emergency department, the fracture rate was higher in more deprived quintiles10.

The sentinel fracture

A wrist fracture predicts a hip fracture. In a meta-analysis of 12 studies the relative risk of hip fracture after wrist fracture was 1.43 in women; in men the increase was not significant11. improve investigation and treatment after fragility fracture: in a meta-analysis of 74 controlled studies of patients aged 50 or older with fragility fractures, they increased bone-density testing, treatment initiation and adherence, and reduced the absolute risk of re-fracture by five percentage points and mortality by three12. A later meta-analysis confirmed fewer subsequent fractures (odds ratio 0.70) but found a mortality benefit only in before-and-after comparisons, not overall13. The British Orthopaedic Association standard requires that patients be assessed for falls risk and bone health and referred to fracture liaison or falls services where appropriate14.

§ 02 · IMAGING AND THE NUMBERS THAT MATTER

Radiographs

Posteroanterior and lateral views centred on the wrist are the standard14. Beyond radial inclination, volar tilt, radial length and , Medoff's review drew attention to the teardrop angle, the anteroposterior distance and articular separation, parameters that reflect the congruity of the articular surface and had been recognised only recently15. The teardrop is the volar rim of the lunate facet on the lateral view, and the teardrop angle is the angle between its central axis and the radial shaft; in fractured wrists it was measured with almost perfect intra- and interobserver reliability, and the teardrop angle relative to volar tilt was associated with articular step and gap on CT16.

The articular surface

In Knirk and Jupiter's study of 43 intra-articular fractures in young adults, arthritis developed in 91 per cent of joints that healed with residual radiocarpal incongruity and in 11 per cent of those that healed congruent; accurate articular restoration was the most critical factor, a die-punch fragment was reduced anatomically by closed means in only 49 per cent, and non-union of the ulnar styloid adversely affected the results17. Radiographic arthrosis does not translate simply into disability: in a separate cohort of 16 young adults reviewed 15 years after open reduction and internal fixation, 13 wrists had radiocarpal arthrosis, yet its presence or degree did not correlate with upper-limb function18. For patients with high functional demands, Ng and McQueen recommended an articular gap or step of less than 2 mm, radial length restored to within 2 mm of normal and restored carpal alignment1.

When to obtain CT

Plain radiographs measure small articular displacements poorly: in Cole's study, 30 per cent of plain-film measurements over- or underestimated displacement compared with CT, and agreement between the two for displacements of 2 mm or more was poor19. Before surgery, CT identified an articular step in 51 per cent of fractures against 30 per cent on radiographs, and the authors judged the two sufficiently different to lead surgeons to choose different treatments20. After closed reduction, CT reclassified 53 per cent of fractures that looked well aligned on radiographs as malaligned, mostly because of intra-articular incongruity, and 73 per cent of those patients went on to surgery21.

The volar lunate facet

The small volar ulnar fragment of the lunate facet contributes to the stability of volar shearing fractures alongside the major fragments. Harness reported seven patients whose volar lunate facet fragment lost fixation after open reduction, with carpal displacement; the anatomy of the distal volar rim may prevent standard implants from supporting it, and the authors advised recognising the injury before the first operation22.

The DRUJ on the first films

In a prospective series of 163 unstable fractures treated with volar plates, 11 had complete radioulnar ligament tears with DRUJ instability; the radial translation ratio — a normalised DRUJ gap on the posteroanterior view — was the most important predictor, with an area under the curve of 0.89 and a best cut-off of 15 per cent23.
Examination notes. PA and lateral views centred on the wrist; teardrop = volar rim of the lunate facet on the lateral view, measured reliably in fractured wrists; a widened DRUJ gap (radial translation) predicts DRUJ instability; CT changes the plan when the joint surface is involved and often reclassifies an "acceptable" reduction.

§ 03 · CLASSIFICATION: USEFUL LANGUAGE, POOR AGREEMENT

AO/OTA and Fernandez

In the comprehensive classification of Müller and colleagues, partial-articular shearing fractures are type B — B1 the radial styloid (the chauffeur's fracture), B2 the dorsal margin and B3 the volar margin (Barton's fracture) — and are unstable, often needing operative fixation; compression fractures of the whole articular surface are type C, from the two-part C1 without metaphyseal comminution to the multifragmentary C324. Fernandez simplified the classification into five groups by mechanism of injury, including the childhood equivalent and the associated DRUJ lesions, with management recommendations25.

Reliability

No system classifies reproducibly beyond its broadest level. Interobserver agreement was fair for the Frykman, Melone and AO classifications and moderate for Mayo; reducing AO to its three types improved agreement, and the authors concluded that none should be the sole basis for treatment or for comparing studies26. Assessors at every level of experience disagreed on AO groups and especially subgroups27. In 456 patients only the AO type (A, B or C) reached substantial intraobserver reliability (κ 0.65)28; in 573 patients even interobserver agreement on type was weak (κ 0.45), and the Frykman and Older classifications could not be recommended29. Adding CT improved intraobserver but not interobserver reliability30.
Examination notes. AO B1 radial styloid (chauffeur's), B2 dorsal rim, B3 volar rim (volar Barton's) — shearing, unstable; C1–C3 compression, by comminution. Know Fernandez as a mechanism-based system that includes the DRUJ. Classification is a language: AO type is the most reproducible level, and even its interobserver agreement can be weak; group and subgroup are not reproducible.

§ 04 · INSTABILITY: WILL IT STAY WHERE IT WAS PUT?

Lafontaine and the factors that followed

Lafontaine's criteria are the only common definition of instability that came from a clinical study; a systematic review found 143 different definitions in the literature31. In the 1989 series of 167 fractures, the read from the first radiograph were dorsal tilt greater than 20°, dorsal comminution, intra-articular radiocarpal involvement, an associated ulnar fracture and comminution of the distal radius, with age over 60 as a further factor of severity; in conservatively treated fractures their sum correlated strongly with secondary displacement despite a satisfactory initial reduction3233. When Nesbitt treated 50 fractures with three or more Lafontaine factors by closed reduction and a sugar-tong splint, 46 per cent held an adequate reduction at four weeks, and age was the only significant predictor of failure — a patient aged 58 carried a 50 per cent risk of secondary displacement34.
Mackenney's prospective analysis of about 4,000 fractures identified age, metaphyseal comminution and ulnar variance as the most consistent predictors of instability and malunion; dorsal angulation did not predict the outcome of displaced fractures, and the patient's independence predicted malunion35. The authors warned that their formulas needed validation before use35, and an external validation found the resulting Edinburgh wrist calculator a poor predictor of redisplacement36. A meta-analysis pooled a significantly higher risk of secondary displacement with dorsal comminution, in women and above 60 years, whereas an associated ulnar fracture or intra-articular involvement did not increase the risk37.

How well do the rules predict?

Modestly. Lafontaine's criteria and the McQueen equation predicted final radial height, inclination and ulnar variance but neither predicted final dorsal tilt or carpal malalignment, whereas hooking the volar cortex at reduction was the strongest predictor of final volar tilt and carpal alignment38. In 274 patients the area under the curve for Lafontaine's criteria was 0.65, which the authors judged unacceptable; age bands, an associated ulnar fracture and initial radial shortening of more than 3 mm did better (0.74)39. A model that added post-reduction and follow-up indicators outperformed the criteria (0.75 against 0.68)40. Small early slips matter: marginal secondary displacement at follow-up (odds ratio 9.7), anterior comminution and loss of anterior apposition predicted late displacement41.
Pitfall. Lafontaine's five radiographic factors plus age over 60 are a historical definition with modest discrimination; age and comminution are the most consistent predictors, dorsal tilt did not predict outcome in displaced fractures, and no calculator has validated well enough to decide treatment alone.

§ 05 · HOW MUCH DEFORMITY MATTERS, AND AT WHAT AGE

The relationship between alignment and function weakens with age. In 216 extra-articular fractures, malalignment was associated with more pain and disability below 65; at 65 and over no isolated radiographic parameter affected the or the Disabilities of the Arm, Shoulder and Hand (DASH) score, although malalignment still carried a higher risk of a poor outcome — eight malaligned fractures would need correction to prevent one poor outcome at 65 and over against two in younger patients42. In 53 patients over 55, radiographic displacement had no effect on subjective or objective outcomes, including timed hand performance43; in 74 conservatively treated patients aged 50 or over, an "acceptable" tilt was not associated with better self-reported function or satisfaction at six months44. Splitting older patients by age, malunion predicted worse early QuickDASH scores at three months in those aged 60–72 but not in those over 77, and predicted neither group's score after a year45.
Radiographic parameters correlate poorly with outcome even after surgery: in 50 fixed fractures, palmar tilt and ulnar variance correlated weakly with patient-reported and physical measures at every interval46. Shortening is the possible exception; in an older series, axial shortening of 3–5 mm already raised the rate of an unsatisfactory functional result47. The BOA and British Society for Surgery of the Hand (BSSH) best-practice document found insufficient evidence for an association between any measured radiological parameter and patient-rated outcome, and its expert panel ranked ulnar variance and dorsal tilt as the most important extra-articular parameters below 65, and the articular step as the most important intra-articular one48. The AAOS/ASSH guideline gives moderate support to operative treatment in patients under 65 with post-reduction radial shortening of more than 3 mm, dorsal tilt of more than 10° or articular displacement of more than 2 mm7.
Controversy. Malalignment matters less with age, but not to zero: the risk of a poor result falls as a gradient after 65 rather than vanishing, and the radiographic thresholds in common use were not derived in older patients.

§ 06 · NON-OPERATIVE TREATMENT

Undisplaced and minimally displaced fractures

In a stepped-wedge cluster randomised trial of 402 patients with non-reduced, undisplaced or minimally displaced fractures, one week of cast followed by mobilisation gave no clinically significant difference in function, pain, satisfaction, secondary displacement or operation rate from three to five weeks of cast49, after a feasibility trial had found the shorter immobilisation feasible and preferred by patients50. Patients should still be warned about the extensor pollicis longus: three of 61 undisplaced fractures (5 per cent) were followed by rupture at an average of 6.6 weeks51.

Manipulation and casting

For manipulation in the emergency department, the National Institute for Health and Care Excellence (NICE) advises considering intravenous regional anaesthesia (Bier's block), performed by trained staff who need not be anaesthetists, and advises against gas and air on its own52. The BOA standard prefers regional anaesthesia to a haematoma block14; the BOA/BSSH document accepts a haematoma block as a safe and viable option when trained staff are not available48.
The type of cast matters less than expected. In a cluster randomised trial of 420 reduced fractures, redisplacement was no less frequent with a circumferential cast than with a plaster splint, although the splint was more painful in the first week53. In 105 patients aged 65 and over, the PRWE differed by 4.3 points in favour of a functional cast over a volar-flexion and ulnar-deviation cast at two years (81 followed up), at roughly half the cost, and the volar-flexion cast was not superior54, and the BOA recommends neutral flexion with three-point moulding rather than forced palmar flexion, with cast removal considered at four weeks14. In a small trial of older patients, four weeks of cast were sufficient55.
Redisplacement is common. In McQueen's trial of 120 redisplaced fractures, re-manipulation, open reduction with bone graft and two forms of external fixation gave the same function at one year; carpal malalignment was the main influence on the final result56. In the Cochrane review of percutaneous pinning, redisplacement leading to secondary treatment occurred in a mean of 12 per cent of participants treated by cast alone57.

Follow-up radiographs

The BOA standard asks for repeat radiographs one to two weeks after injury or manipulation when the pattern is thought unstable and further displacement would lead to surgery, and not at removal of immobilisation unless there is clinical concern14. The AAOS found limited evidence of no difference in outcome with the frequency of radiographic evaluation7. In the DRIFT trial of patients aged 65 or over, plating fractures that lost alignment in the first 5–10 days gave no significant benefit, and the authors questioned early radiographic follow-up during non-operative treatment58.

§ 07 · OPERATIVE TREATMENT: WHAT THE TRIALS COMPARED

Wires or plate: DRAFFT

DRAFFT randomised 461 adults in 18 UK trauma centres with a dorsally displaced fracture within 3 cm of the radiocarpal joint that needed fixation; fractures whose joint surface needed open reduction were excluded. There was no clinically relevant difference in the PRWE at three, six or 12 months (difference −1.3 in favour of the plate, 95 per cent confidence interval −4.5 to 1.8), in quality of life or in complications, and Kirschner wires were cheaper and quicker4. At five years there was still no clinically relevant difference — PRWE 8.3 after wires and 11.3 after plates — although only 44 per cent of participants provided scores, and only three needed further surgery in the whole cohort59. The trial changed practice: in England, K-wire fixation rose from 12 to 42 per cent of operations for isolated distal radius fractures and plating fell from 75 to 48 per cent2. In a two-centre trial of 45 patients, plating against pinning gave better DASH scores to 12 weeks but no difference at one year60.

Wires or cast: DRAFFT2

DRAFFT2 randomised 500 adults (mean age 60) in 36 National Health Service hospitals after manipulation of a dorsally displaced fracture to a moulded cast or K-wires plus cast. The PRWE at 12 months did not differ (21.2 against 20.7), nor did earlier scores; 33 patients (13 per cent) in the cast group needed fixation for loss of position within six weeks, against one revision after wires5. Wires left less dorsal angulation at six weeks (a mean difference of about 4°), but radiographic measurements did not correlate with patient-reported outcomes at any point in the year61.

External fixation

External fixation maintains reduction better than a cast (redisplacement needing secondary treatment 7 of 356 against 51 of 338) but without proven functional superiority62. Against the volar plate, one meta-analysis found DASH scores favouring the plate but clinically meaningful only at three months, with more reoperation after plating and more infection after external fixation63; another, of 12 randomised trials, found lower DASH scores after plating at 3, 6 and 12 months64. In a randomised trial followed for three years, function did not differ and the reoperation rate was 21 per cent after plating against 14 per cent after external fixation65. The BOA/BSSH document advises against external fixation as definitive treatment of closed fractures when internal fixation is possible48.

Working-age adults

The evidence for surgery is strongest below 60–65. In the VIPER trial of 92 patients aged 18 to 75 with acceptably reduced extra-articular fractures, plating gave better DASH scores at every time point to a year; 28 per cent of the casted group redisplaced and were plated, 14 per cent had a corrective osteotomy, and 42 per cent had some further operation66. In Ochen's meta-analysis of 23 studies (8 of them randomised), operative treatment improved the medium-term DASH by 5.2 points overall and by 7.5 points in studies of adults of all ages, with no significant improvement (−1.0 points) in studies restricted to patients aged 60 or over67.

Older adults: plate or cast

Seven trials and their meta-analyses frame the debate.
  • CROSSFIRE, in 19 centres in Australia and New Zealand, randomised 166 patients aged 60 or over to a volar plate or closed reduction and cast; the 12-month PRWE did not differ (19.8 against 21.5), nor did quality of life, pain or complications, but more patients after plating rated the treatment a success (89 against 70 per cent)3; the 24-month PRWE again showed no clinically important difference68.
  • WRIST, in 304 patients aged 60 or over, randomised plating, external fixation and pinning, with casting by patient choice: recovery was fastest after plating, and by 12 and 24 months no group differed meaningfully; casting had the most malunion (59 per cent), which was not associated with the 24-month outcome6970.
  • Arora randomised 73 patients aged 65 or over: plating gave earlier recovery and better grip and alignment, equal PRWE and DASH at six and 12 months, and more complications (13 against five)71.
  • Hassellund found casting non-inferior on QuickDASH at a year in 100 patients aged 65 and over, although plated patients recovered faster and were more satisfied72.
  • VOLCON found no difference in complications or function to 12 months in patients over 6573.
  • ORCHID, in AO type C fractures in patients aged 65 or over, found no significant difference in SF-36 at one year; 37 patients allocated to casting had secondary surgery for loss of reduction74.
  • Saving's is the trial that favours the plate: in 140 older patients, PRWE, DASH and grip were better after plating at three and 12 months, with similar complication rates75.
The 2025 DRIFT trial added nuance: in patients aged 65 or over whose fractures were malaligned after reduction, plating improved the 12-month PRWE by 9.6 points, less than the predefined minimal clinically important difference of 11; when alignment was lost later, plating gave no significant benefit58. Meta-analyses agree: no improvement in DASH in studies of patients aged 60 or over67, a 4.1-point DASH difference at 12 months across eight trials in adults of any age, well below the 10-point threshold76, and more major complications and tendon injury after surgery in older patients77. The AAOS/ASSH guideline rates as strong the evidence that operative treatment in patients 65 and over does not improve long-term patient-reported outcomes, and treats age 65 as a proxy for functional demand7.
Controversy. In older patients the plate buys a faster recovery, better grip, straighter radiographs and higher patient-rated success, not better wrist function at one to two years; the decision is about speed of recovery, the patient's demands and the patient's acceptance of a second procedure if the cast fails.

Technique, timing and the volar fracture

The AAOS/ASSH guideline found strong evidence of no difference in outcome between fixation techniques for complete articular or unstable fractures, with earlier recovery to three months after volar plating, and inconsistent evidence of no benefit from arthroscopic assistance7. NICE recommends K-wires when the articular surface is intact or can be reduced closed, considering open reduction when it cannot, and surgery within 72 hours of injury for intra-articular fractures and within seven days for extra-articular ones52. The BOA standard adds that volar displaced fractures are unstable and should be considered for open reduction and plate fixation14.

§ 08 · COMPLICATIONS OF THE VOLAR PLATE

How often

Reported complication rates depend on what is counted. A systematic review of prospective studies found 16.5 per cent, most of them minor78; a review of randomised trials found 30.8 per cent, 12.4 per cent major, led by median nerve problems (7.1 per cent) and plate removal (6.8 per cent), with CRPS in 2.4 per cent and tendon rupture in 1.3 per cent79. In Arora's multicentre series of 114 patients (a prospective protocol analysed retrospectively) the rate was 27 per cent, more than half of it flexor or extensor tendon irritation, including two ruptures each of flexor pollicis longus and extensor pollicis longus80. A retrospective series of 822 patients reported 12.3 per cent overall and 4.8 per cent major81, and in a series of 594 patients the major plate-related complications were intra-articular screws and tendon rupture82.

Flexor tendons and the watershed line

Among flexor tendon ruptures after volar plating, flexor pollicis longus is the tendon most often affected; the mechanism is usually impingement on a plate placed beyond the watershed line, on a fracture healed in dorsal tilt or on a prominent screw, and the median interval to rupture in reported cases was eight months83. The grades prominence on the lateral radiograph: a line is drawn tangential to the most volar extent of the volar rim, parallel to the volar cortex of the shaft; grade 0 plates do not project volar to it, grade 1 plates lie volar to it but proximal to the rim, and grade 2 plates lie on or distal to the volar rim. In Soong's series of one plate design, three of 73 plated radii ruptured a flexor tendon, two of them with grade 2 plates — present in 63 per cent of that series — whereas a lower-profile design had neither grade 2 plates nor ruptures in 95; the authors advised avoiding prominence whatever the implant84. Its interrater reliability is high, although intrarater agreement varied between observers85. In Kitay's case-control study a higher Soong grade was associated with rupture, and plate prominence of more than 2.0 mm volar to the critical line or a plate within 3.0 mm of the volar rim identified ruptures with high accuracy; the authors suggested considering removal after union in symptomatic patients with such plates86. Pooled across 56 studies, rupture of flexor pollicis longus followed 0.6 per cent of volar plates87.

Extensor tendons and the dorsal cortex

Extensor tendon rupture after volar plating has been reported in 0 to 12.5 per cent of patients, most often of extensor pollicis longus, with dorsal screw prominence and fracture fragments among the risk factors88; in a five-year review of 303 patients, all 12 tendon complications were attributed to technical errors of implant placement, including three ruptures of extensor pollicis longus from dorsally protruding screws89. The dorsal tangential view finds some protruding screws but not all: in a prospective cohort it led to revision of screws in 32 per cent of patients, yet postoperative CT found further screws protruding at least 1 mm in 20 per cent, a sensitivity of 52 per cent90. In another comparison three-dimensional fluoroscopy did not outperform the tangential view, and the second compartment was prone to penetration whichever imaging was used91.

Plate removal

Removal rates vary from 0 to 100 per cent between studies, with a mean of 9 per cent; frequent removal did not improve clinical outcomes92.
Pitfall. On the post-fixation lateral radiograph look for a Soong grade 2 plate on or beyond the volar rim — the flexor pollicis longus risk — and do not rely on the dorsal tangential view alone to exclude a long screw in the second or third compartment.

The median nerve

In a large claims database, 9.2 per cent of patients were diagnosed with within six months of the fracture, and 19.8 per cent of those treated surgically93. In a propensity-matched cohort, releasing the carpal tunnel at the time of fixation did not reduce later carpal tunnel release, and the authors did not support routine release94. Neither study addresses acute compression of the presenting with the fracture.

§ 09 · THE DRUJ AND THE ULNAR STYLOID

When the DRUJ is stable after fixation of the radius, the ulnar styloid fracture does not affect outcome. After volar plating, styloid fractures did not change the Michigan Hand Outcomes Questionnaire scores in patients with a stable DRUJ; the three patients found intraoperatively to be unstable had styloid fixation and were excluded95. Neither the level nor the displacement of the styloid fracture related to outcome in Kim's series, in which chronic DRUJ instability developed in 1.4 per cent of wrists96. Two meta-analyses found that an associated styloid fracture97 and a styloid non-union98 did not worsen outcome, and a randomised trial of 86 patients with basal styloid fractures and a stable DRUJ after plating found fixation unnecessary99. The BOA/BSSH document asks that DRUJ stability be assessed and recorded after surgical treatment, and finds styloid fixation unnecessary when the joint is clinically stable48.
Instability found at operation does not necessarily need repair. In 84 patients, intraoperative DRUJ laxity treated with a month of forearm immobilisation did not affect pain or disability at a year100. In 157 patients whose DRUJ was unstable on ballottement after fixation, transfixation or arthroscopic repair of the triangular fibrocartilage complex gave better early motion than a supination sugar-tong splint, but long-term motion and wrist scores were similar101. The examination of the DRUJ is covered in the clinical examination article.
Examination notes. Fix the radius, then test the DRUJ and record the result; a styloid fracture — tip or base, united or not — does not matter when the DRUJ is stable; acute laxity can be treated by immobilisation in supination, with operative stabilisation an option rather than a requirement.

§ 10 · CRPS AND VITAMIN C

The reported incidence of CRPS depends on the definition. In a Danish register of 247,128 fractures, a diagnosis of CRPS within a year was recorded in 0.20 per cent — 0.31 per cent after surgery and 0.17 per cent without — which the authors regarded as a minimum102; in Zollinger's dose-response trial the rate in the placebo group was 10.1 per cent103.
The vitamin C story is a lesson in evidence. Zollinger's first trial found reflex sympathetic dystrophy in 7 per cent of wrists given 500 mg of vitamin C daily for 50 days against 22 per cent after placebo104; the dose-response trial found 2.4 per cent against 10.1 per cent, all affected patients being elderly women, recommended 500 mg daily for 50 days, and found early cast complaints a strong predictor of CRPS103. Ekrol's double-blind trial of 336 patients then found no effect on DASH, CRPS or healing at one year105. Two meta-analyses of essentially the same trials disagree: pooling three trials (890 patients), vitamin C did not reduce CRPS (risk ratio 0.45, 95 per cent confidence interval 0.18 to 1.13)106; pooling the 500 mg arms, it did (risk ratio 0.54, 0.33 to 0.91)107. The earlier AAOS guideline recommended vitamin C, and a review applying Hill's criteria found six of nine met and judged the recommendation to have practical merit108. The 2020 AAOS/ASSH recommendations do not address vitamin C7, and the BOA/BSSH document does not recommend it48.
Controversy. Vitamin C for CRPS rests on two positive trials from one group and is contradicted by a later negative double-blind trial; the meta-analyses split depending on whether the estimate is restricted to the 500 mg arms, and British best-practice guidance does not recommend it.

§ 11 · MALUNION

Malunion is quoted at about 23 per cent after non-operative and 11 per cent after operative treatment; in a single-centre series of 48 corrective osteotomies, 38 per cent of patients had a complication needing further treatment, and bone graft made no difference to function109. Six years after osteotomy in 89 patients, the median PRWE was 22, and an associated ulnar styloid fracture was the only independent factor for a worse score110. In the WRIST trial, malunion after casting in patients aged 60 or over was not associated with the 24-month outcome70.

§ 12 · REHABILITATION AND OUTCOME MEASURES

Therapy

The Cochrane review found the randomised evidence insufficient to establish the relative effectiveness of rehabilitation interventions111. After plating, a home exercise programme was an effective alternative to prescribed physiotherapy112; after casting, adding exercise to structured advice brought no extra benefit113, and an advice leaflet or video gave DASH scores at six weeks that did not differ significantly from face-to-face therapy, although face-to-face therapy scored better on the DASH work subscale114. Supervised physiotherapy helped patients over 60 with extra-articular fractures at six weeks and a year, but by two years only grip strength still differed115, and a 2026 meta-analysis reported short-term benefits, including a PRWE difference of 11.6 points at six weeks116. The AAOS/ASSH guideline describes the evidence comparing home and supervised therapy as inconsistent7.

Early motion after plating

Early mobilisation after plating without bone graft was safe and improved motion and grip at six months in a pilot trial117; in another trial the difference between early and late motion had disappeared after six weeks118.

Measuring the result

The is reliable, valid and responsive across wrist and hand conditions119, and is the primary outcome of DRAFFT, DRAFFT2, CROSSFIRE and DRIFT. DRIFT used 11 points as the minimal clinically important difference58. The BOA/BSSH document makes an interim recommendation for the PRWE or the DASH as the 48. In a Finnish working-age cohort the median time off work was 49 days after conservative and 70 days after operative treatment120.

§ 13 · WHAT THE GUIDELINES SAY

Three sets of guidance overlap and occasionally differ.
  • AAOS/ASSH (2020): seven statements: strong evidence that surgery does not improve long-term patient-reported outcomes at 65 and over and that fixation techniques do not differ beyond earlier recovery after plating; moderate support for surgery below 65 beyond the shortening, tilt and step thresholds, and moderate evidence against arthroscopic assistance; limited or inconsistent evidence on supervised therapy and radiograph frequency; a consensus statement on opioid-sparing analgesia7.
  • NICE NG38 (2016): Bier's block for manipulation in the emergency department, manipulation and a plaster cast to be considered for dorsally displaced fractures, K-wires when the joint is intact or closed-reducible, and surgery within 72 hours for intra-articular and within seven days for extra-articular fractures52.
  • BOA standard (2017) and BOA/BSSH best-practice document (2018): non-operative treatment can be considered at 65 and over unless there is significant deformity or neurological compromise; below 65, ulnar variance, articular step and dorsal tilt are weighed against the patient's needs; volar displaced fractures should be considered for plating; cast in neutral with three-point moulding for about four weeks; bone-health and falls assessment14; DRUJ stability recorded after fixation; vitamin C not recommended48.
The AAOS/ASSH guideline and the BOA use age 65 as a proxy for functional demand, whereas NICE does not stratify by age; AAOS/ASSH and the BOA/BSSH document both leave the decision to an informed discussion with the patient.

§ 14 · EXAMINATION POINTS

  • AO type B is partial articular: B1 radial styloid (chauffeur's), B2 dorsal rim, B3 volar rim (volar Barton's); AO type is the most reproducible level, group and subgroup are not.
  • Lafontaine's factors are dorsal tilt over 20°, dorsal comminution, intra-articular involvement, associated ulnar fracture and comminution, plus age over 60; Mackenney found age, metaphyseal comminution and ulnar variance the most consistent predictors.
  • DRAFFT: no clinically relevant difference between K-wires and volar plates at one and five years. DRAFFT2: casting after manipulation matched K-wires at a year, at the price of 13 per cent later fixation.
  • In patients over 60–65, plating gives faster recovery and better alignment but no clinically important gain in wrist function at one to two years (CROSSFIRE, WRIST, Arora, Hassellund, meta-analyses; Saving is the exception).
  • Soong grade 2 plates lie on or beyond the volar rim and are associated with flexor pollicis longus rupture; long dorsal screws threaten the extensor pollicis longus.
  • An ulnar styloid fracture does not need fixation when the DRUJ is stable after radius fixation.
  • The vitamin C evidence for CRPS conflicts; know both trials and both meta-analyses.
  • Every fragility fracture is a prompt for bone-health assessment and a fracture liaison service.