01Approach to the Critical Patient/attcp42

Immediate priorities

›Limb-threatening emergencies

›Vascular compromise

›Absent radial or ulnar pulse

›Pallor or cyanosis of digits

›Capillary refill > 3 seconds

›Acute compartment syndrome

›Tense forearm compartments

›Pain with passive finger extension

›Paresthesias out of proportion to injury

›Open fracture

›Wound communicating with fracture site

›Bone visible or palpable

›If vascular compromise or open fracture, emergent orthopedic consultation

›Operative intervention may be required urgently

›Tetanus prophylaxis for open fractures

Key decision points

›Severity stratification

›Non-displaced or minimally displaced

›Conservative management with splinting

›No reduction required

›Displaced fracture requiring reduction

›Post-reduction radial shortening > 3 mm

›Dorsal tilt > 10 degrees

›Intra-articular step-off > 2 mm

›Elderly patient (>= 65 years)

›Surgical fixation does not improve patient-reported outcomes over conservative management

›CROSSFIRE trial and AAOS guideline support conservative approach in most geriatric patients

02History/hx52

Mechanism and onset

›Injury mechanism

›Fall on outstretched hand (FOOSH)

›Forearm pronated and wrist dorsiflexed

›Low-energy in elderly; high-energy in young

›High-energy mechanisms in younger patients

›Motor vehicle collision

›Sports injury or cycling fall

›Time elapsed since injury

›Affects reduction success and swelling

›Guides analgesia strategy

Symptom characterization

›Pain profile

›Focal wrist pain at time of injury

›Inability to grip or bear weight through wrist

›Exacerbation with movement

›Neurovascular symptoms

›Numbness or tingling in thumb through radial half of fourth finger

›Median nerve distribution involvement in up to 25%

›Associated injuries from fall

›Elbow or shoulder pain

›Hip or head injury if fall from height

Risk factors and context

›Osteoporosis risk factors

›Postmenopausal female (lifetime risk 16.6% vs 2.9% in men)

›Age > 50 years

›Early menopause or low body weight < 58 kg

›Medication exposures

03Physical Exam/exam46

Inspection and palpation

›Classic deformity assessment

›Dinner fork (silver fork) deformity

›Dorsal angulation and prominence of distal fragment

›Radial shortening visible on comparison

›Swelling and ecchymosis

›Diffuse periarticular swelling

›Ecchymosis development over hours

›Open wounds

›Communication with fracture site

›Contamination or gross debris

›Tenderness localization

›Distal radius palpation

›Dorsal and volar distal radius tenderness

›Fracture site crepitus

›Adjacent structure palpation

›Anatomic snuffbox tenderness (scaphoid)

›Ulnar styloid tenderness

›Lunate tenderness

Neurovascular exam

›Median nerve assessment

›Motor function

›Thumb opposition to fifth finger against resistance

›Thenar muscle bulk and tone

›Sensory function

›Palmar surface of thumb through radial half of fourth finger

›Two-point discrimination if available

›Vascular assessment

04Differential Diagnosis/ddx50

Distal radius fracture variants

›Smith fracture (reverse Colles)

›ICD-10 S52.509A

›Volar displacement of distal fragment

›Fall on dorsum of wrist or over handlebars

›Distinguishing feature from Colles

›Garden spade deformity (palmar vs dorsal angulation)

›Higher rate of instability and surgical fixation

›Barton fracture

›ICD-10 S52.509A

›Intra-articular rim fracture with radiocarpal dislocation

›High-energy mechanism required

›CT essential for characterization

›Articular step-off assessment

›Ligamentous injury assessment

›Chauffeur (Hutchinson) fracture

›Radial styloid avulsion fracture

›Intra-articular extension common

›Associated scaphoid and lunate injuries

›CT evaluation recommended

›Intercarpal ligament injury screening

Carpal and ligamentous injuries

›Scaphoid fracture

›ICD-10 S62.001A

›Most common carpal fracture

›Anatomic snuffbox and scaphoid tubercle tenderness

›Missed on initial X-ray in up to 30%

›MRI gold standard if clinical suspicion persists

05Laboratory Tests/lt30

Routine labs

›Labs generally not required for isolated Colles' fracture

›No infection or systemic illness component

›Isolated musculoskeletal injury

›Healthy adults with classic mechanism do not require bloodwork

›Exception: procedural sedation planning

›Point-of-care glucose if diabetic

›Baseline vital signs and oximetry sufficient in most

Labs for surgical candidates

›Pre-operative baseline if surgery anticipated

›Complete blood count

›Baseline hemoglobin for surgical planning

›Platelet count if anticoagulated or bleeding concern

›Basic metabolic panel

›Renal function for anesthesia and contrast planning

›Electrolyte status

›Coagulation studies if anticoagulated

›INR for warfarin therapy

›Anti-Xa level for direct oral anticoagulants

Osteoporosis evaluation labs

›Outpatient metabolic bone workup in fragility fracture

›Calcium and phosphorus

›Hyperparathyroidism screening

›Hypercalcemia of malignancy

›25-OH vitamin D level

›Deficiency highly prevalent in fragility fracture patients

›Target repletion to > 75 nmol/l

›TSH

06Diagnostic Tests/dt93

Scoring Systems

›Fracture instability assessment thresholds (AAOS/ASSH guideline)

›Radiographic instability criteria

›Post-reduction radial shortening > 3 mm

›Dorsal tilt > 10 degrees after reduction

›Intra-articular step-off > 2 mm

›Comminution markers

›Dorsal comminution predicts redisplacement

›Intra-articular involvement raises surgical threshold

›Clinical instability markers

›Age < 65 years with anatomic instability favors surgical fixation

›Age >= 65 years: surgical vs conservative outcomes equivalent per CROSSFIRE trial

›Frykman classification

›Distinguishes extra- vs intra-articular involvement

›Types I-IV extra-articular with or without ulnar styloid fracture

›Types V-VIII intra-articular with or without ulnar styloid fracture

›Higher Frykman class correlates with instability

›Guides surgical decision-making

›Ulnar styloid base fracture associated with DRUJ instability

›AO/OTA classification

›Group A: extra-articular

›A1 ulnar fracture only

›A2 distal radius simple extra-articular

›A3 distal radius complex extra-articular

›Group B: partial articular

›Partial joint surface involvement

›Group C: complete articular

›Full articular disruption; highest surgical rate

›FRAX fracture risk score

›10-year fracture probability calculation

›Age, sex, BMI, prior fracture history inputs

›Parental hip fracture as independent risk factor

›Indicated for patients >= 50 years with fragility fracture

›Guides osteoporosis pharmacotherapy decisions

›Thresholds for treatment vary by national guideline

MRI

›MRI wrist indications in Colles fracture context

›Occult scaphoid fracture suspicion

›Negative radiograph with anatomic snuffbox tenderness

›MRI sensitivity > 95% for occult scaphoid fracture

›Ligamentous injury characterization

›Scapholunate ligament tear evaluation

›TFCC (triangular fibrocartilage complex) injury

›Avascular necrosis screening

›Delayed presentation with persistent pain

›Lunate or scaphoid AVN characterization

›MRI limitations in acute setting

›Not routinely required for typical displaced Colles fracture

›Radiographs and CT sufficient for acute management

›MRI reserved for diagnostic uncertainty

›Availability and time constraints

›Rarely available emergently

›Outpatient follow-up imaging when appropriate

CT

›CT wrist indications

›Intra-articular fracture characterization

›Articular step-off quantification

›Comminution pattern mapping

›Surgical planning

›Fragment size and position for volar locking plate

›Dorsal comminution assessment

›Complex fracture patterns

›Chauffeur or Barton fracture evaluation

›Carpal injury associated with distal radius fracture

›CT performance characteristics

›Superior to plain radiograph for articular step-off

›Changes surgical plan in up to 23% of cases

›Recommended for intra-articular fractures pre-operatively

›Not routine for extra-articular Colles fractures

›Radiograph sufficient for most extra-articular patterns

›CT when clinical doubt about intra-articular extension

Ultrasound

›Point-of-care ultrasound (POCUS) applications

›Fracture confirmation

›Cortical disruption visible on high-frequency linear probe

›Useful when radiograph equivocal or unavailable

›Nerve block guidance

›Ultrasound-guided median nerve block at wrist

›Distal median nerve block or forearm-level block

›Hematoma block guidance

›Real-time needle guidance into fracture hematoma

›Confirmation of lidocaine spread within hematoma

›Ultrasound for vascular assessment

›Radial artery Doppler

›Confirm flow in suspected vascular injury

›Post-reduction reassessment if pulse quality changed

›Operator-dependent limitation

›Bone and soft tissue artifact

›Adjunct to clinical assessment, not replacement

›Plain radiograph as primary imaging

›PA, lateral, and oblique views

›Radial inclination normal approximately 23 degrees

›Radial height normal approximately 11 mm

›Volar tilt normal approximately 11 degrees volar

›Post-reduction films mandatory

›Confirm restoration of alignment

›Assess for intra-articular step-off

07Disposition/dispo53

Discharge criteria

›Criteria for safe discharge from ED

›Fracture management complete

›Non-displaced: splinted with instructions

›Displaced: reduction performed with acceptable post-reduction alignment

›Intact neurovascular status

›Radial and ulnar pulse present

›Median nerve intact or baseline deficit documented

›Adequate pain control

›Oral analgesia effective at home

›No uncontrolled pain requiring IV medication

›Reliable follow-up arranged

›Orthopedic or fracture clinic within 3-5 days

›Patient able to comply with instructions

Admission and operative indications

›Indications for hospital admission

›Open fracture requiring operative washout

›Wound irrigation and debridement urgently

›Antibiotics initiated in ED (cefazolin 2 g IV)

›Vascular compromise requiring repair

›Absent radial pulse after reduction attempt

›Vascular surgery consultation

›Acute compartment syndrome

›Emergent fasciotomy required

›Monitor for renal injury from rhabdomyolysis

›Failed closed reduction requiring operative fixation

›Unstable pattern with unacceptable alignment

›Concurrent complex carpal injury

08Treatment/t117

Analgesia

›First-line oral analgesia

›Ibuprofen 400-600 mg PO

›Combined with acetaminophen 1000 mg PO

›Combination as effective as oral opioids for acute extremity pain (JAMA 2017 RCT)

›Acetaminophen 1000 mg PO alone

›If NSAID contraindicated (renal impairment, GI bleeding, anticoagulation)

›Can repeat every 6 hours

›Opioid-sparing approach recommended by AAOS

›NSAIDs and acetaminophen first-line

›Opioids reserved for inadequate control; limit to <= 7 days

›Topical and non-pharmacologic analgesia

›Ice application to wrist

›15-20 minutes every 2 hours while awake

›Barrier between ice and skin

›Elevation above heart level

›Reduces swelling and pain

›Pillow support at rest

›Topical NSAIDs

›ACP/AAFP guideline recommends as primary therapy for musculoskeletal pain

›Diclofenac gel as alternative to systemic NSAIDs

Procedural analgesia for reduction

›Hematoma block technique

›Most commonly used method for ED reduction (approximately 75% of reductions)

›Inject 5-10 mL of 1% lidocaine without epinephrine

›Into fracture hematoma under sterile technique

›Onset 5-10 minutes

›Contraindications: allergy, open fracture (infection risk)

›Supplement with IV analgesia if inadequate

›Procedural sedation

›Ketamine IV 1-2 mg/kg for dissociative sedation

›Onset 60-90 seconds

›Duration 10-20 minutes

›Propofol IV 1-2 mg/kg induction dose

›Airway management equipment at bedside

›Fasting status assessment

›Midazolam plus fentanyl

›Midazolam 0.05-0.1 mg/kg IV

›Fentanyl 1-2 mcg/kg IV

›Ultrasound-guided nerve block

›Distal median nerve block at wrist level

›3-5 mL 1% lidocaine under real-time ultrasound guidance

›Targets median nerve in carpal tunnel

›Forearm-level brachial plexus block

›Consider for complex reductions

›Anesthesia or trained ED provider

Closed reduction technique

›Reduction maneuver steps

›Longitudinal traction applied to fingers

›Finger trap traction or manual traction

›5-10 minutes of traction to disimpact fragments

›Distal fragment manipulation

›Correct dorsal angulation

›Restore volar tilt and radial length

›Ulnar deviation to correct radial shortening

›Restore radial inclination

›Maintain reduction while splint applied

›Acceptable post-reduction alignment

›Radial shortening < 3 mm

›Compared to contralateral wrist

›Dorsal tilt < 10 degrees (volar tilt preferred)

›Aim for restoration of neutral or volar tilt

›No significant intra-articular step-off

›Step-off < 2 mm acceptable

›Post-reduction films mandatory before splint finalized

Immobilization

›Splinting technique

›Sugar-tong splint for displaced fractures post-reduction

›Prevents forearm rotation

›Wrist in neutral to slight volar flexion and ulnar deviation

›Volar short-arm splint for non-displaced stable fractures

›Wrist in neutral position

›Thumb spica extension if scaphoid injury suspected

›Splint to cast transition

›Short-arm cast at 1-2 week follow-up

›Once swelling subsided

›Confirm maintained alignment before cast application

›Immobilization duration

›Non-displaced fractures: 3-6 weeks total

›Recent evidence supports 3 weeks for stable non-displaced fractures

›Displaced or reduced fractures: 6 weeks typical

Surgical management

›Indications for operative fixation

›Persistent instability after closed reduction

›Radial shortening > 3 mm

›Dorsal tilt > 10 degrees

›Articular step-off > 2 mm

›Open fracture

›Cefazolin 2 g IV initiated within 1 hour of presentation

›Washout and debridement in OR

›Acute vascular injury or compartment syndrome

›Fasciotomy and fracture stabilization combined

›Surgical fixation options

›Volar locking plate (most common)

›No difference in functional outcomes between fixation techniques at 3 months

›Preferred for most unstable patterns

›Percutaneous K-wire fixation

›Cochrane review: similar functional outcomes to plate at 1 year

›Lower cost; risk of pin tract infection and stiffness

›External fixation

›Complex comminution or open fractures

›Adjunct to internal fixation in some patterns

›Geriatric surgical considerations

›Age >= 65 years: no functional benefit of surgery over conservative management

›CROSSFIRE trial: equivalent patient-reported outcomes

›Conservative management preferred in most geriatric patients

›Exceptions may include bilateral fractures or specific functional demands

›Individualized shared decision-making

›Comorbidity and anesthetic risk assessment

Post-fracture bone health

›Osteoporosis pharmacotherapy indications

›Bisphosphonate therapy for high-risk patients

›Alendronate 70 mg PO weekly (ACP/AACE guideline)

›Risedronate 35 mg PO weekly as alternative

›Zoledronic acid 5 mg IV annual infusion

›For patients unable to tolerate oral bisphosphonates

›ACEP and ACP support initiation after fragility fracture

›Calcium and vitamin D supplementation

›Calcium 1000-1200 mg/day in divided doses

›Vitamin D 600-800 IU/day (higher doses for deficiency)

›Denosumab 60 mg SC every 6 months

›For severe osteoporosis or bisphosphonate intolerance

›Do not discontinue without bridging therapy (rebound fracture risk)

09Special Populations/sp100

Pregnancy

›Pregnancy-specific considerations

›Mechanism more likely low-energy fall

›Altered center of gravity increases fall risk

›Ligamentous laxity from relaxin may affect wrist stability

›Imaging approach

›Plain radiographs with lead shielding are safe

›Fetal radiation dose from wrist X-ray is negligible

›CT wrist if needed for surgical planning

›Fetal dose from extremity CT is low but minimize when possible

›MRI preferred over CT when equivalent information expected

›Analgesia in pregnancy

›Acetaminophen 1000 mg PO generally considered safe

›Preferred analgesic in all trimesters

›Limit to short-term use

›NSAIDs in first and second trimester

›Short-course ibuprofen acceptable up to 28-32 weeks

›Avoid in third trimester (premature ductus arteriosus closure)

›Opioids

›Short-term use with monitoring; neonatal withdrawal risk

›Minimize use; prefer non-opioid alternatives

›Procedural analgesia for reduction

›Hematoma block with lidocaine preferred

›Avoid large volumes of systemic agents

›Ketamine used cautiously in second trimester

›Involve obstetrics for sedation in late pregnancy

›Aspiration risk increased in pregnancy

›Fetal monitoring if viable gestation

Geriatric

›Age-related fracture pattern differences

›Low-energy fall from standing height most common mechanism

›Osteoporotic bone fails with minimal force

›Treat as sentinel osteoporotic fracture

›Higher rate of comminution

›Intra-articular extension more common

›Redisplacement after reduction more frequent

›DRUJ injury and ulnar styloid base fracture more common

›Increased stiffness risk post-treatment

›Conservative management preference in elderly

›Surgical fixation does not improve outcomes vs conservative for most patients >= 65

›CROSSFIRE trial: equivalent PRWE and DASH scores at 12 months

›Patient preference and functional demands guide decision

›Acceptable radiographic criteria may be less strict

›Greater malunion tolerance if functional outcome maintained

›Avoid aggressive interventions in frail patients

›Medication safety in geriatric patients

›NSAIDs with caution

›Renal impairment common; check eGFR

›GI bleeding risk; consider PPI co-prescription

›Avoid opioids where possible

›Fall risk and delirium risk

›Acetaminophen preferred

›Procedural sedation risk higher

›Reduced hepatic and renal clearance

›Titrate carefully; consider hematoma block alone

›Frailty and functional assessment

›Ability to perform ADLs with one hand immobilized

›Home support assessment

›Occupational therapy referral if needed

›Fall prevention plan

›Physiotherapy for balance and gait

›Home hazard assessment

›Cognitive status

›Compliance with splinting instructions

›Need for caregiver involvement

Pediatrics

›Pediatric distal radius fracture differences

›Greenstick and torus (buckle) fractures more common in children

›Cortex buckles rather than complete displacement

›Torus fracture: volar buckle, stable, splint or removable brace

›Growth plate involvement (Salter-Harris classification)

›Salter-Harris I: physeal separation (often normal radiograph)

›Salter-Harris II: most common; metaphyseal fragment

›Remodeling capacity

›Significant remodeling potential in younger children

›More displacement acceptable in children far from skeletal maturity

›Analgesia in children

›Ibuprofen 10 mg/kg PO every 6-8 hours

›Maximum 40 mg/kg/day

›Preferred first-line in children

›Acetaminophen 15 mg/kg PO every 4-6 hours

›Combination with ibuprofen for moderate pain

›Maximum 75 mg/kg/day

›Intranasal fentanyl for procedural analgesia

›1.5-2 mcg/kg intranasal

›Rapid onset; useful before hematoma block

›Reduction and immobilization in children

›Hematoma block with 1% lidocaine (weight-based: 0.5 mL/kg, max 10 mL)

›Procedural sedation preferred for younger or anxious children

›Nitrous oxide inhalation as adjunct

›Cast immobilization rather than splint for most pediatric fractures

›Short-arm cast for most distal radius fractures

›Long-arm cast for Salter-Harris fractures or proximal extension

›Orthopedic referral for growth plate injuries

›Salter-Harris III and IV require anatomic reduction

›Growth arrest risk counseling for parents

›Child protection consideration

›Inconsistent mechanism with injury pattern

›Non-accidental trauma if history does not fit

›Bilateral injuries or multiple fractures at different stages

›Safeguarding referral if concerns present

›Document mechanism carefully

›Social work involvement as appropriate

10Background/b75

Epidemiology

›Incidence and prevalence

›Most common forearm fracture in adults

›Estimated 250,000-300,000 distal radius fractures per year in the United States

›Bimodal age distribution: young males (high-energy) and postmenopausal females (low-energy)

›Lifetime risk

›Women: approximately 16.6% lifetime risk

›Men: approximately 2.9% lifetime risk

›Peak incidence in postmenopausal women aged 60-69 years

›Osteoporosis major contributory factor

›Wrist fracture often precedes hip fracture by a decade

›Sentinel event significance

›Colles' fracture in postmenopausal woman is a fragility fracture

›Indicates underlying osteoporosis until proven otherwise

›Prior fragility fracture strongest predictor of future fracture

›Hip fracture risk elevated after distal radius fracture

›FRAX score calculation recommended for all patients >= 50 years

›Fracture liaison service reduces secondary fracture rate by 30-40%

›Complications epidemiology

›Stiffness most common long-term complication at 11.5% at 1 year

›Range of motion loss most functionally limiting

›Median neuropathy most common early complication

›Acute carpal tunnel syndrome in up to 25%

›Malunion rate higher in conservatively managed unstable fractures

›Acceptable in elderly; functionally limiting in younger active patients

›Complex regional pain syndrome (CRPS) incidence 3-7%

›Early mobilization and vitamin C may reduce risk

Pathophysiology

›Fracture mechanism

›FOOSH impact transfers axial load through carpus to distal radius

›Forearm pronated and wrist dorsiflexed at impact

›Failure at metaphyseal-diaphyseal junction

›Dorsal comminution from compressive forces

›Cortical failure on tension side volarly

›Dorsal cortex impacted on compressive side

›Radial shortening from impaction

›Radial height loss correlates with instability

›Ulna relative lengthening produces DRUJ incongruence

›Osteoporotic bone failure pattern

›Trabecular bone loss reduces compressive strength

›Metaphysis especially vulnerable to osteoporotic change

›Cortical thinning reduces bending resistance

›Low-energy failure threshold in osteoporosis

›Standing height fall produces fracture that would not occur in healthy bone

›Comminution more extensive with lower bone density

›Median nerve injury mechanism

›Acute compression from fracture displacement and hematoma

›Carpal tunnel contents compressed

›Neuropraxia most common; usually resolves with reduction

›Acute carpal tunnel syndrome

›Elevated tunnel pressure causes ischemic neuropathy

›Surgical decompression if fails to resolve after reduction

Therapeutic Considerations

›Evidence base for treatment selection

›Opioid vs non-opioid analgesia evidence

›JAMA 2017 RCT: single-dose opioid not superior to ibuprofen plus acetaminophen for acute extremity pain

›ACP/AAFP guideline supports NSAIDs and acetaminophen as first-line

›Surgical vs conservative in elderly

›CROSSFIRE trial (JAMA Surgery 2022): no difference in PRWE scores at 12 months

›Multiple systematic reviews support conservative management preference in >= 65

›Percutaneous K-wire vs volar locking plate

›Cochrane review: similar functional outcomes at 1 year

›Plate fixation has higher complication rate in some series; lower redisplacement rate

›Immobilization duration evidence

›Recent evidence supports 3 weeks for stable non-displaced fractures

›Early mobilization reduces stiffness

›Earlier weight-bearing through wrist acceptable

›Unstable or reduced fractures: 6 weeks is standard

›AAOS guideline supports this duration

›Osteoporosis secondary prevention

›Fracture liaison services reduce secondary fracture risk by 30-40%

›Systematic identification, investigation, and treatment

›Bisphosphonate therapy reduces future fracture risk by 30-50%

›ACP living guideline recommends pharmacotherapy for high-risk patients

›AACE guideline provides specific thresholds for initiation

›Calcium and vitamin D as adjuncts to pharmacotherapy

›Not sufficient as monotherapy for high-risk patients

›Essential as foundational treatment

11Patient Discharge Instructions/pdi51

copy discharge instructions

›Wrist fracture home care

›Keep splint or cast dry at all times

›Use a plastic bag or waterproof cast cover for showering

›Do not insert anything inside the cast

›Ice application to wrist over the cast

›20 minutes every 2 hours while awake for the first 48-72 hours

›Place a cloth barrier between ice and skin or cast

›Elevation above heart level

›Keep wrist elevated on pillows when sitting or lying

›Reduces swelling and pain significantly

›Analgesia as directed

›Take ibuprofen and acetaminophen regularly for first 48-72 hours

›Do not take more than prescribed amounts

›Finger and hand exercises

›Move all fingers fully (make a full fist, then fully extend) every 1-2 hours

›Keeps circulation and finger function maintained

›Do not move the wrist itself while splinted

›Thumb and shoulder exercises

›Full shoulder range of motion to prevent stiffness

›Thumb movement if not in thumb spica

›Return to emergency department immediately for

›Increasing numbness or tingling in fingers

›May indicate nerve compression or compartment syndrome

›Increasing severe pain especially with passive finger straightening

›Warning sign of compartment syndrome requiring urgent care

›Color changes in fingers

›Blue, white, or purple fingers suggest circulation problem

12References/r37

Guidelines and key sources

›AAOS and ASSH clinical practice guidelines

›Management of Distal Radius Fractures: AAOS Evidence-Based Clinical Practice Guideline 2020

›Kamal RN, Shapiro LM. JAAOS 2022; PMCID PMC9196973

›Covers surgical thresholds, immobilization, and osteoporosis evaluation

›AAOS/ASSH practical application guideline summary

›Kamal RN, Shapiro LM. JAAOS 2022; PMCID PMC9035062

›Instability criteria: shortening > 3 mm, dorsal tilt > 10 degrees, step-off > 2 mm

›Key randomized controlled trials

›CROSSFIRE trial: Plating vs closed reduction in elderly

›JAMA Surgery 2022; Lawson A et al.

›No significant difference in PRWE scores at 12 months for patients >= 65 years

›Chang AK et al. JAMA 2017: Opioid vs non-opioid for acute extremity pain

›Single-dose ibuprofen plus acetaminophen equivalent to opioid

›Supports opioid-sparing approach in ED

›Cochrane systematic reviews

›Karantana A et al. Cochrane 2020: Percutaneous pinning vs volar locking plate

›Similar functional outcomes at 1 year

›Handoll HH et al. Cochrane 2007: External fixation vs conservative

›No clear advantage to external fixation in most patients

›Handoll HH et al. Cochrane 2003: Closed reduction methods

›Evidence base for standard reduction techniques

›Osteoporosis and bone health guidelines

›ACP living guideline: Pharmacologic Treatment of Primary Osteoporosis 2023

›Qaseem A et al. Annals of Internal Medicine 2023; PMCID PMC10885682

›AACE/ACE Postmenopausal Osteoporosis Guidelines 2020

›Camacho PM et al. Endocrine Practice 2020

›Osteoporosis JAMA 2025: Morin SN, Leslie WD, Schousboe JT

Evidence & Review