Commentary

Debate exists about the degree to which normal anatomy needs to be restored after distal radial fracture. Most clinicians agree that the articular surface should be made congruous, that shortening should be minimised, and that palmer tilt should be restored to at least neutral.¹ The methods to achieve and maintain reduction can be grouped into casting and percutaneous or open techniques, although many variations of each exist.

Most clinicians consider high energy multifragmentary distal radial fractures with intra-articular displacement as distinct from low energy fractures with a congruous joint when choosing appropriate treatment. However, many of the studies in the review by Handoll and Madhok have inappropriately evaluated all injuries together. The myriad of treatment variations described, the wide range of outcomes evaluated, and the lack of injury discrimination have made it difficult to draw firm conclusions from the literature. Casting is associated with the highest probability of a poor anatomic result, especially in high energy injuries and those with metaphyseal comminution. Alternative treatment to casting should be considered when an acceptable reduction cannot be achieved or when residual joint incongruity and metaphyseal redisplacement is likely especially in high energy injuries. It seems reasonable to approach these high energy injuries with minimally invasive techniques and to resort to open reduction if anatomic restoration is not possible. The role of arthroscopy and adjunctive bone grafting or substitution to obtain and maintain reduction has yet to be elucidated.²

Large prospective trials with appropriate injury discrimination and consistent outcome evaluation are needed before firm recommendations can be made about the degree of anatomic restoration required, and the best treatment to use in a particular situation. Existing practices are based largely on expert opinion.