› Multimodal analgesia approach
› Acetaminophen 650-1000 mg oral every 6-8 hours
› First-line for mild to moderate pain
› Maximum 4000 mg/24 hours
› Ibuprofen 400-600 mg oral every 6-8 hours
› With food
› Avoid if renal impairment or bleeding risk
› Naproxen 500 mg oral every 12 hours as alternative NSAID
› Opioids for severe or breakthrough pain only
› Oxycodone 5 mg oral every 4-6 hours PRN
› Limit prescription to approximately 20 tablets
› Schedule with acetaminophen and NSAID base
Hematoma block for reduction
› Hematoma block technique
› 5-10 mL of 1% lidocaine injected into fracture hematoma
› Needle entry from dorsal-radial approach
› Aspiration of dark blood confirms fracture hematoma entry
› Onset of analgesia within 5-10 minutes
› Can combine with ulnar nerve block for ulnar-sided pain
› Alternative: procedural sedation
› Consider ketamine or propofol for anxious or uncooperative patients
› Required for complex reductions needing complete muscle relaxation
› ECG and monitoring if procedural sedation planned
Closed reduction technique
› Reduction method
› Apply longitudinal traction for 5-10 minutes to disimpact fragments
› Dorsally directed pressure on the volar-displaced distal fragment
› Wrist placed in slight dorsiflexion (10-20 degrees) and supination
› Dorsiflexion counteracts deforming pull of wrist flexors
› Distinctly different from Colles reduction which uses palmar flexion
› Avoid Cotton-Loder position (palmar flexion): precipitates median nerve neuropathy
› Post-reduction splinting
› Well-molded sugar-tong splint
› Splint in slight dorsiflexion and supination
› Adequate padding to prevent pressure sores
› Confirm neurovascular status after splinting
› Post-reduction PA and lateral radiographs mandatory
› Indications for surgical fixation
› Failure to achieve or maintain acceptable reduction
› Post-reduction radial shortening >3 mm
› Dorsal tilt >10 degrees
› Intra-articular step-off >2 mm
› Open fracture
› Concurrent radiocarpal dislocation or DRUJ instability
› Neurovascular compromise
› Volar locking plate fixation
› Most commonly used technique for Smith fractures
› Provides stable fixation of volar-displaced fragment
› Allows earlier functional recovery compared to cast immobilization
› Recommended for non-geriatric patients (<65 years) failing reduction parameters
› AAOS/ASSH guideline: operative treatment recommended for non-geriatric patients
› Geriatric surgical decision
› Strong evidence shows no difference in patient-reported outcomes between operative and non-operative treatment in patients >65 years
› Conservative management reasonable for elderly with acceptable reduction
› Shared decision making with patient and orthopedics
› Percutaneous pinning
› Alternative to plate fixation for select fracture patterns
› Cochrane review (2020) supports role in adults for distal radius fractures
› Higher risk of pin tract infection compared to plate fixation
Immobilization and rehabilitation
› Immobilization duration
› 3-6 weeks depending on fracture stability and healing
› Shorter for operative fixation with stable plate
› Longer for conservative management of unstable patterns
› Post-operative rehabilitation
› Removable wrist brace after operative fixation
› Early digit range of motion exercises
› Formal occupational or physiotherapy referral
› Grip strength recovery may take up to 12 months
Antibiotic prophylaxis for open fractures
› Antibiotic selection by contamination grade
› Cefazolin 2 g IV for clean open fractures (Gustilo I-II)
› Add metronidazole 500 mg IV for grossly contaminated wounds
› Add gentamicin 5 mg/kg IV for farm or soil contamination
› Administer within 1 hour of injury presentation
› Continue until 24 hours post-operative closure
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