Distal radius and ulna fractureMANAGEMENT

FOREARM, WRIST & HAND · 12 SECTIONS

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432 items

☷ Legend

01Approach to the Critical Patient/attcp52

Immediate priorities

›Limb threat screen

›Open fracture features

›Visible bone

›Wound near fracture with active bleeding

›Contamination

›Fracture blisters with skin breakdown

›Neurovascular status

›Radial pulse

›Ulnar pulse

›Capillary refill

›Skin temperature and color

›Median nerve function

›Thumb opposition

›Palmar index finger sensation

›Ulnar nerve function

›Finger abduction

›Palmar little finger sensation

›Radial nerve function

›Thumb IP extension

›Dorsal first web space sensation

›If pulseless or rapidly worsening perfusion, immediate reduction and splinting

›If persistent ischemia after reduction, immediate hand/vascular surgery and transfer

›Compartment syndrome risk

›Pain out of proportion

›Escalating pain despite analgesia

›Pain with passive finger extension

›Tense volar forearm compartments

›Paresthesia progression

›If concern, immediate orthopedic consultation and transfer capability

›Constriction relief

›Ring removal

›Bracelet and watch removal

›Splint loosening if increasing tightness after immobilization

Imaging and stabilization workflow

›Early imaging pathway

›Wrist radiographs before definitive splinting when feasible

›Immediate reduction before radiographs for threatened skin or neurovascular compromise

›Post-reduction radiographs mandatory

›Consultation triggers

›Open fracture

›Neurovascular compromise

›Acute carpal tunnel syndrome concern

›Irreducible deformity

›Unstable pattern on imaging

›DRUJ instability concern

›Pain and sedation readiness

›Hematoma block suitability

›Bier block suitability in trained setting for dorsally displaced distal radius fractures (NICE) :contentReference[oaicite:0]{index=0}

›Procedural sedation readiness for complex reduction

›Documentation checkpoints

›Neurovascular exam pre-reduction

›Neurovascular exam post-reduction

›Neurovascular exam post-splint

02History/hx35

Mechanism and context

›Injury context

›FOOSH mechanism

›Direct blow to wrist

›High-energy mechanism

›MVC

›Fall from height

›Sports collision

›Low-energy mechanism with fragility risk

›Timing

›Time since injury

›Time since any manipulation attempt

›Progressive swelling trajectory

›Baseline function

›Hand dominance

›Occupation and functional demands

›Baseline wrist ROM and grip limits

›Symptoms and red flags

›Numbness or tingling in hand

›Increasing pain despite analgesia

›Finger weakness or loss of thumb opposition

›Cold or pale hand

›Skin tenting or blistering

›Relevant risks

›Anticoagulants and antiplatelets

›Bleeding disorder

›Diabetes

›Peripheral vascular disease

›Osteoporosis risk

›Chronic steroid use

›Prior fracture or wrist surgery

›Associated injuries

›Elbow pain

›Shoulder pain

›Head injury features after fall

›Other fractures in polytrauma

03Physical Exam/exam40

Wrist and forearm exam

›Deformity and skin

›Dinner fork deformity

›Volar angulation deformity

›Skin tenting

›Abrasions and puncture wounds near fracture

›Fracture blisters

›Palpation and stability

›Distal radius tenderness

›Distal ulna and ulnar styloid tenderness

›DRUJ tenderness

›Snuffbox tenderness

›Motion and function limits

›Finger active ROM

›Thumb opposition

›Pain with passive stretch of fingers

›Neurovascular exam

›Radial pulse

›Ulnar pulse

›Capillary refill

›Median nerve sensory distribution

›Ulnar nerve sensory distribution

›Radial nerve sensory distribution

›Two-point discrimination trend if median nerve concern

›Tendon checks

›EPL integrity

›Thumb IP extension against resistance

›Finger extensor integrity

›Flexor tendon integrity

›DRUJ assessment

›Ulnar head prominence

›Painful forearm rotation

›DRUJ instability suspicion after reduction

›Joint above and below

›Elbow tenderness and ROM

›Shoulder tenderness and ROM

PITFALLS

›Pitfall patterns

›Under-recognition of acute carpal tunnel syndrome

›Missed scaphoid fracture with wrist pain

›Missed elbow injury with forearm fracture mechanism

›Failure to reassess neurovascular status after splinting

04Differential Diagnosis/ddx31

Primary and common co-injuries

›Distal radius fracture patterns

›Colles fracture

›Smith fracture

›Barton fracture

›Chauffeur fracture

›Die-punch fracture

›Distal ulna injuries

›Ulnar styloid fracture

›Distal ulnar metaphyseal fracture

›TFCC injury

›DRUJ and carpal injuries

›DRUJ instability

›Perilunate injury

›Scaphoid fracture

›Lunate fracture

›Neurovascular complications

›Acute carpal tunnel syndrome

›New CTS diagnosis within 6 months after distal radius fracture reported around 9% in a large database study :contentReference[oaicite:1]{index=1}

›Radial artery injury

›Soft tissue mimics

›Wrist sprain

›Tendon rupture

Coding alignment

›ICD-10-CM candidates

›S52.5 Distal radius fracture

›S52.6 Distal ulna fracture

›S52.61 Ulnar styloid fracture

›SNOMED CT concepts

›Distal radius fracture

›Colles fracture

›Smith fracture

›Ulnar styloid process fracture

05Laboratory Tests/lt19

Routine and selective labs

›Default approach

›No routine labs for isolated closed stable fractures

›Pain control and imaging prioritized

›Open fracture or operative pathway

›CBC for bleeding concern

›Electrolytes and creatinine for peri-procedural planning

›INR for warfarin or liver disease

›Type and screen for open fracture with significant bleeding

›Compartment syndrome or crush concern

›CK for rhabdomyolysis concern

›Creatinine and potassium for renal risk

›Procedural sedation pathway

›Point-of-care glucose if altered mental status

›Pregnancy test if relevant and results change imaging or meds

Interpretation and pitfalls

›Limitations

›Normal labs do not exclude compartment syndrome

›Normal INR does not exclude antiplatelet effect

›Documentation relevance

›Anticoagulation status for hematoma block bleeding risk discussion

06Diagnostic Tests/dt39

Scoring Systems

›Classification frameworks

›AO/OTA distal radius classification

›Type A extra-articular

›Type B partial articular

›Type C complete articular

›Salter-Harris for pediatric physeal injury suspicion

›Type I through V pattern awareness

›Clinical application

›Intra-articular involvement as instability marker

›Comminution as instability marker

›DRUJ involvement as instability marker

Radiographs

›Standard radiographs

›Wrist views

›PA

›Lateral

›Oblique

›Forearm views when ulnar shaft or proximal injury concern

›Elbow views when elbow pain or high-energy mechanism

›Post-reduction imaging

›Alignment confirmation after reduction and splint

›DRUJ congruity assessment

›Alignment parameters informing fixation discussion

›Radiographic parameters used by AAOS guideline for considering fixation in many adults under 65

›Radial shortening greater than 3 mm

›Dorsal tilt greater than 10 degrees

›Intra-articular step-off greater than 2 mm :contentReference[oaicite:2]{index=2}

MRI

›Occult injury pathways

›Suspected scaphoid fracture with negative radiographs

›MRI as first-line imaging option in NICE non-complex fracture guidance for suspected scaphoid fracture after exam :contentReference[oaicite:3]{index=3}

›TFCC injury suspicion with persistent ulnar-sided wrist pain

›Use considerations

›Persistent pain with normal radiographs

›Ligamentous injury suspicion

›Indications

›Intra-articular distal radius fracture characterization

›Pre-operative planning for complex articular injury

›Occult fracture suspicion with persistent pain and equivocal X-ray

›Clinical rationale

›Articular step-off quantification to guide management discussion

07Disposition/dispo27

ED disposition pathways

›Discharge criteria

›Closed fracture

›Neurovascularly intact

›Pain controlled with oral regimen

›Reliable follow-up and return precautions

›Splint tolerated without increasing tightness

›Admission criteria

›Open fracture

›Neurovascular compromise

›Acute carpal tunnel syndrome concern

›Compartment syndrome concern

›Uncontrolled pain

›Polytrauma or unsafe discharge environment

›Transfer criteria

›Vascular injury concern

›Compartment syndrome concern

›Open fracture needing urgent operative care

›Irreducible deformity

›Specialist hand surgery need not available locally

Follow-up timing

›Follow-up planning

›Early orthopedic follow-up after reduction

›Repeat radiographs per local protocol for unstable patterns

›Timing targets referenced in BOAST distal radius guidance

›Intra-articular fractures and re-displacement after manipulation

›Surgery target within 72 hours :contentReference[oaicite:4]{index=4}

›Extra-articular fractures

›Surgery target within 1 week :contentReference[oaicite:5]{index=5}

08Treatment/t107

Immediate life-saving interventions

›Limb-threatening complications

›If pulseless or threatened perfusion, immediate reduction and splinting

›If persistent ischemia post-reduction, emergent transfer for vascular capability

›If open fracture, antibiotics and tetanus pathway before definitive management when feasible

›Constriction relief

›Ring removal before swelling progresses

›Hemorrhage control for open injury

›Direct pressure

›Hemostatic dressing when needed

Immobilization and Splinting

›Splint selection

›Upper extremity options

›sugar tong

›volar wrist

›posterior long arm

›radial gutter

›Distal radius and ulna fractures typical choice

›sugar tong for acute swelling and forearm rotation control

›Positioning principles

›Wrist slight extension

›MCP joints free for motion when possible

›Avoid circumferential cast in early swelling phase

›Splint technique essentials

›Extra padding over ulnar styloid and radial styloid

›Edge flaring to reduce pressure injury

›Two-finger tightness check

›Post-splint reassessment

›Median nerve status

›Capillary refill

›Radial and ulnar pulses

›Pain trend after immobilization

Reduction

›Indications for reduction

›Neurovascular compromise

›Threatened skin or severe tenting

›Marked deformity with functional compromise

›Unacceptable alignment on radiographs

›Contraindications or caution triggers

›Suspected vascular injury needing immediate specialist involvement

›Open fracture

›Antibiotics and tetanus pathway first when feasible

›Analgesia and anesthesia options

›Non-opioid adjuncts

›Acetaminophen PO 1000 mg

›Ibuprofen PO 400 mg to 600 mg

›Opioid titration options

›Fentanyl IV 25 mcg to 50 mcg increments

›Hydromorphone IV 0.2 mg to 0.5 mg increments

›Local anesthesia options

›Hematoma block

›Lidocaine 1% without epinephrine 10 mL

›Aspiration before injection

›Maximum lidocaine dose 4.5 mg/kg

›Regional anesthesia options

›Bier block for dorsally displaced distal radius fracture reduction in adults when trained resources available (NICE) :contentReference[oaicite:6]{index=6}

›Contraindications

›Sickle cell disease

›Severe peripheral vascular disease

›Inability to monitor tourniquet safely

›Procedural sedation pathway

›Ketamine IV

›Initiate 0.5 mg/kg to 1 mg/kg

›If inadequate effect after 1 to 2 minutes, additional 0.25 mg/kg to 0.5 mg/kg

›Maximum cumulative dose per local protocol

›Propofol IV

›Initiate 0.5 mg/kg to 1 mg/kg

›Additional 0.25 mg/kg to 0.5 mg/kg boluses

›Hypotension risk mitigation with fluids and dose reduction

›Monitoring and readiness

›Continuous pulse oximetry

›Cardiac monitoring

›Capnography when available

›Airway equipment ready

›Reduction technique principles

›Traction and countertraction

›Deformity exaggeration to disengage fragments

›Reverse mechanism correction

›Gentle sustained force

›Avoid repeated forceful attempts

›Post-reduction requirements

›Immediate neurovascular reassessment

›Post-reduction radiographs

›Splinting in stable position

›Failed reduction pathway

›Persistent neurovascular deficit triggers immediate escalation

›Irreducible deformity triggers urgent orthopedics

›Worsening pain with tight compartments triggers compartment syndrome escalation

Open fracture medications and timing

›Antibiotics and timing

›First dose as early as possible after recognition

›Cefazolin IV 2 g

›Severe beta-lactam allergy

›Clindamycin IV 900 mg

›Gross contamination or farm injury

›Add gentamicin IV 5 mg/kg

›Tetanus prophylaxis

›Tdap or Td if immunization not up to date

›Tetanus immune globulin if high-risk wound and incomplete immunization

›Wound care principles

›Sterile saline-soaked dressing

›Avoid wound probing in ED unless necessary for hemorrhage control

›Consultation and transfer

›Immediate orthopedics or hand surgery involvement

DVT prophylaxis when relevant

›Upper extremity immobilization default

›Pharmacologic DVT prophylaxis not routine for isolated distal radius fractures

›Risk-based consideration

›Prior VTE history

›Active cancer

›Prolonged immobility for other injuries

›Alignment with local protocol

09Special Populations/sp28

Pregnancy

›Pregnancy considerations

›Shielding for radiographs when feasible

›Medication safety

›Avoid NSAIDs in later pregnancy per local obstetric guidance

›Opioid minimization strategy

›Fall risk and syncope evaluation when indicated

›Obstetric consultation when trauma mechanism significant

Geriatric

›Fragility fracture framing

›Low-energy FOOSH as osteoporosis signal

›Secondary fracture prevention referral pathway

›Management considerations

›Higher risk of loss of reduction with dorsal comminution

›Lower threshold for admission for pain control or unsafe home environment

›Delirium risk with opioids and sedation

›Epidemiology note

›Distal radius fracture incidence in elderly reported between 200 and 1200 per 100,000 person-years :contentReference[oaicite:7]{index=7}

Pediatrics

›Pediatric fracture patterns

›Buckle fracture

›Greenstick fracture

›Salter-Harris physeal injury

›Exam priorities

›Growth plate tenderness

›Neurovascular exam adapted to age

›Management considerations

›Remodeling potential with angulation tolerance by age and location

›Non-accidental trauma consideration when history inconsistent

›Analgesia dosing

›Weight-based acetaminophen and ibuprofen per local protocol

10Background/b23

Epidemiology

›Population patterns

›Higher incidence in women than men across adult ages in epidemiologic studies :contentReference[oaicite:8]{index=8}

›Increasing incidence reported in large registry datasets

›Overall incidence reported around 228 per 100,000 per year in one national study :contentReference[oaicite:9]{index=9}

›Co-injury frequency

›Ulnar styloid fractures associated with distal radius fractures in more than 50% in a systematic review summary :contentReference[oaicite:10]{index=10}

Pathophysiology

›Mechanism to pattern mapping

›FOOSH with wrist extension leading to dorsal displacement patterns

›FOOSH with wrist flexion leading to volar displacement patterns

›Axial load causing intra-articular die-punch injury

›DRUJ and TFCC relevance

›Ulnar styloid base fracture as possible DRUJ instability marker

›DRUJ instability assessment required regardless of ulnar styloid union status debate :contentReference[oaicite:11]{index=11}

›Complication mechanisms

›Median nerve compression from swelling or fragment displacement

›EPL tendon vulnerability after distal radius fracture

Therapeutic Considerations

›Alignment and functional outcomes

›Goal of optimizing function rather than radiographs alone emphasized in BOAST :contentReference[oaicite:12]{index=12}

›Fixation consideration thresholds in many adults

›AAOS guideline uses radiographic thresholds in adults under 65 to guide operative consideration :contentReference[oaicite:13]{index=13}

›Analgesia and reduction guidance

›Bier block considered for dorsally displaced distal radius fracture reduction in adults in ED when trained (NICE) :contentReference[oaicite:14]{index=14}

›Gas and air alone not recommended for this reduction in adults (NICE) :contentReference[oaicite:15]{index=15}

11Patient Discharge Instructions/pdi25

copy discharge instructions

›Discharge instructions

›Splint care

›Keep splint clean and dry

›Do not insert objects to scratch under splint

›Check fingers for swelling and color change

›Swelling control

›Elevation above heart as much as possible for 48 hours

›Ice over splint 10 to 15 minutes at a time if tolerated

›Activity limits

›No lifting with injured wrist

›Finger range of motion encouraged if allowed by splint

›Pain plan

›Acetaminophen as directed

›Ibuprofen as directed if safe for patient

›Opioid only if prescribed and needed

›Follow-up

›Orthopedic or fracture clinic follow-up per discharge plan

›Return for repeat radiographs if scheduled

›Return to ED immediately

›Increasing pain not controlled with medication

›New numbness or tingling in fingers

›Fingers becoming pale, blue, cold, or hard to move

›Increasing tightness under splint

›Splint becomes wet, broken, or too tight

›Fever or wound drainage if any wound present

12References/r6

Guidelines and evidence sources

›AAOS Management of Distal Radius Fractures Clinical Practice Guideline, published December 5, 2020 :contentReference[oaicite:16]{index=16}

›BOAST The Management of Distal Radial Fractures, December 2017 :contentReference[oaicite:17]{index=17}

›NICE NG38 Fractures (non-complex) assessment and management, recommendations including distal radius reduction anesthesia guidance :contentReference[oaicite:18]{index=18}

›Epidemiology of distal radius fractures review article (PMC) :contentReference[oaicite:19]{index=19}

›Incidence of carpal tunnel syndrome after distal radius fracture national database study (PMC) :contentReference[oaicite:20]{index=20}

›Systematic review summary on ulnar styloid fractures with distal radius fractures (PMC) :contentReference[oaicite:21]{index=21}

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.