What is your diagnosis?

Distal radius metaphysis fracture.

Does this fracture need reduction? How do you know?

As shown in Image 2, measuring the degree of displacement can help decide if reduction is necessary. Without intraarticular or physeal extension, these fractures can be safely managed non-operatively if treated correctly.

Image 2. Author’s own image and annotation, showing 15.5 degrees of dorsal angulation

• Pearl: Although opinions vary on the exact degree, published literature suggests that for pre-adolescents, up to 30 degrees of dorsal angulation can be tolerated, and for adolescents, up to 15 degrees [1]. Bone remodeling in displaced pediatric fractures has been shown to average 13 degrees of correction, with acceptable levels of function even in those without perfect alignment. If a question exists, reduction can always be performed, or consult your orthopedic surgeon.

• Pearl: Although the AP image is not shown, evaluating malrotation and angulation on all images is important. In this case the AP did not show significant displacement or rotation.

For this patient, dorsal pressure was applied with application of a sugar-tong splint, which was enough to cause improved alignment of the fracture.

 Image 3. Author’s own image, Post-Reduction and Splinting

If you do reduce, what options for pain control do you have?

Pain medication (narcotics, ketorolac, etc), sedation (conscious or unconscious with propofol, ketamine, etc), or a hematoma block. For isolated distal radius fractures, hematoma blocks have been shown to be noninferior to sedation for pain control in adult and pediatric patients, while also being safe, efficient, and easy to perform [3,4]. 

• Pearl: To perform a hematoma block, after cleaning the area, anesthetic (i.e. lidocaine) is injected into the area of hematoma caused by the fracture. This can be done using landmark, ultrasound, or C-arm guidance. Once numb, the fracture can be manipulated. Even if not performing a true reduction, this can assist in splinting the patient in a more comfortable manner while reducing the use of systemic pain medication. 

What is your disposition? When do you need orthopedics?

Once the fracture is splinted, the patient can be referred to outpatient orthopedics in 1-2 weeks for repeat radiographs to assure proper alignment is being maintained. Usual guidelines for referral, which include open fractures, neurovascular compromise, or concern for compartment syndrome, still apply.