Hand Clin 21 (2005) 307–316
Closed Manipulation and Casting of Distal
Radius Fractures
Diego L. Fernandez, MD
University of Bern, Department of Orthopaedic Surgery, Lindenhof Hospital, CH-3012, Bern, Switzerland
Given that most epidemiologic studies [1–5] on
fractures of the distal radius have combined
several different fracture patterns, it is still difficult
to assess the real incidence of extra-articular and
intra-articular injuries, and it is even more com-
plex to appreciate the occurrence of stable and
unstable fracture types. For this reason it is
impossible to produce an accurate estimate on
the overall percentage of distal radius fractures
that can reliably be treated conservatively. In an
exhaustive review of 2,141 fractures McQueen [5]
using the AO classification identified 1,029 extra-
articular (type A) fractures accounting for 48% of
the population, 219 (10%) partial articular frac-
tures (type B), and 893 (42%) complete articular
fractures (type C). Of the extra-articular group
(48%) 15% were minimally displaced (A2.1
types), and therefore theoretically amenable to
cast immobilization, whereas the most common
fracture pattern was the dorsally displaced with
dorsal metaphyseal comminution (A3.2 types,
26%). This group most probably included the
more unstable fracture patterns, for which cast
treatment is usually contraindicated.
In view of the current overwhelming sophisti-
cation of surgical management of distal radius
fractures with predictable outcomes, it has be-
come difficult for the younger generation to
recognize which fracture types may be treated
with a classic closed reduction and plaster immo-
bilization and still guarantee a good functional
result. It is important to keep in mind that to
achieve anatomic results with conservative treat-
ment, the surgeon must possess the same or even
better technical abilities when applying a plaster
E-mail address: diegof@bluewin.ch
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.02.004
cast than those needed to perform external or
internal fixation of a wrist fracture. Conservative
fracture treatment is more cumbersome, because
frequent radiographic and clinical controls and
possible cast changes are necessary to assess the
quality of reduction and to prevent secondary
displacement or detect misdiagnosed unstable
fracture patterns that may require early secondary
external or internal stabilization. To a certain
extent this may explain why many fractures that
perhaps would heal in a cast in an acceptable
position are primarily over-treated with external
or internal fixation just to eliminate the risk for
secondary displacement in a cast. Furthermore, in
patients who demand early use of the hand, some
distal radius fractures that may fall into the
category of displaced but stable are fixed in-
ternally but would otherwise be amenable to
cast treatment.
The basic decision that has to be taken when
dealing with a distal radius fracture is whether or
not it can be treated conservatively (closed manip-
ulation and cast immobilization) or surgically.
Several factors, such as age, bone quality, occupa-
tion, and general condition of the patient, together
with characteristics of the fracture, associated
lesions, and the surgeon’s experience with different
treatment modalities, must all be taken into con-
sideration to select the best treatment. Although
occasionally a fracture that, because its character-
istics represent an absolute surgical indication, has
to be treated in a cast because of the bad general
condition of the patient, the basic parameters to
decide for a conservative management are whether
or not the fracture is reducible with closed manip-
ulation and if it remains stable after reduction; in
other words, those fractures in which the tendency
to re-displace in plaster is minimal.
hand.theclinics.com
308 FERNANDEZ

The aims of conservative treatment are to

obtain and maintain anatomic realignment of
the fracture for a period of 4 weeks, the time at
which bony union is well advanced, so that the
risk for secondary displacement at that stage is
practically nonexistent. It must be kept in mind,
however, that contrary to skeletal fixation by
a bridging implant that controls interfragmentary
motion, the position of the distal fragment is
maintained indirectly by external cast contact,
tension on soft tissue structures, and by the
hydraulic pressure of the soft tissue envelope.
The greater the initial displacement, cortical
comminution, and cancellous bone impaction,
the greater the amount of settling of the fracture
in the cast is therefore to be expected, despite the
use of a meticulous casting technique.

Indications for conservative treatment

Conservative treatment of distal radius frac-
tures in adults is recommended and reliable for
nondisplaced extra-articular and intra-articular
fractures, for displaced fractures that remain
stable following closed reduction, and certain
unstable fractures in elderly patients, in which
the surgeon accepts the possibility of a tolerable
amount of secondary displacement, which falls in Fig. 1. Natural history of an unstable extra-articular
the category of an asymptomatic, well functioning dorsal bending fracture. (A) Initial anteroposterior and
malunion. lateral radiographs demonstrate wide displacement of
the distal fragment. The radiographs fail to depict
The decision making for nonoperative man-
accurately the comminution of the dorsal metaphyseal
agement is based on a large body of clinical and cortical and cancellous bone. (B) Initial AP and lateral
experimental evidence [6–15] that has demon- radiographs following fracture reduction and plaster
strated a strict correlation between the quality of immobilization. (C) As early as 1 week after reduction
reduction, the radiographic result, and the func- the radiographs demonstrate loss of reduction with the
tional outcome and also on the analysis of the distal fragment beginning to displace in a dorsal and
radiographic criteria of instability [16,17]. Frac- radial direction. (D) At 6 weeks after fracture it has
tures that show on initial radiographs more than nearly returned to its original position. (E) At 8 weeks’
20( of dorsal (or palmar) angulation, a displace- postinjury extreme displacement has occurred with
ment of more than two thirds the width of the deformity involving the radiocarpal and radioulnar
articulations.
shaft in any direction, metaphyseal comminution,
more than 5 mm of shortening, intra-articular
component, an associated ulnar fracture, or ad-
vanced osteoporosis are considered unstable, with angulation less than 5( and shortening less than
a high risk for secondary displacement in a cast, 2 mm (Fig. 2).
despite acceptable initial reduction and correct
plaster techniques (Fig. 1). On the other hand,
stable fractures are those that do not displace at Conservative management
the time of presentation or following manipulative
Nondisplaced fractures
reduction [18–21]. Abbaszadegan et al [22] defined
stable extra-articular fractures as those present- Bending fractures of the distal radius that
ing with minimal displacement having dorsal present with little or no displacement result in
 DISTAL RADIUS FRACTURES: CLOSED MANIPULATION, CASTING
the great majority of cases with an excellent
functional outcome and have a long-term favor-
able prognosis [23–26]. Fractures with minimal
displacement (5( of dorsal tilt and shortening less
than 2 mm) or impacted fractures are stable even
when supported with elastic bandages rather than
plaster casts (Fig. 2). The author, however, prefers
to immobilize them for a period of 3–4 weeks in
a dorsal splint or a well molded below-elbow cast
followed by a removable wrist brace until the
patient feels comfortable, usually 5–6 weeks
following injury. One complication that seems to
be uniquely associated with nondisplaced distal
radius fracture is the spontaneous rupture of the
extensor pollicis longus tendon [27–29]. Most of
these ruptures occur within the first 2 months after
the fracture, their etiology attributed to attrition
and hypovascularity of the tendon at the level of
Lister’s tubercle.
Displaced fractures
Closed reduction is indicated for displaced
fractures in which there is radiographic evidence
that a stable realignment of the fracture fragments
can be achieved and that the minimal residual
Fig. 2. (A) Minimally displaced dorsally impacted distal radius fracture. (B) No reduction necessary, dorsal plaster splint
support. (C) Radiographs at 5 weeks showing fracture healed in the initial position.
309
interfragmentary motion can be controlled with
meticulous casting technique.
Adequate anesthesia, depending on the local
soft tissue conditions, is imperative. Fracture
hematoma block, intravenous regional, brachial
plexus block, and general anesthesia have specific
indications. The first two usually are selected for
low energy displaced fractures without significant
swelling.
With dorsally displaced fractures, the author
prefers to infiltrate the fracture site following
aspiration of the hematoma with 5–10 cm of 1%
or 2% Lidocaine without epinephrine, with the
point of entrance of the needle on the volar side,
because the dorsally impacted cortex may not
always permit the needle to enter the fracture site
easily. A second injection is recommended in the
area of the distal radioulnar joint and ulnar
styloid. The two most common disadvantages of
the fracture hematoma block are insufficient
analgesia and muscle relaxation. For these rea-
sons fracture hematoma block should be reserved
for simple, readily reducible fracture patterns.
Axillary blocks are indicated especially if a difficult
reduction is anticipated, as in fractures seen late,
in re-manipulations, and in instances in which
local skin and soft tissue contusions or open
310 FERNANDEZ
wounds and significant edema contraindicate the
use of local anesthesia. General anesthesia is
reserved for pediatric fractures or for patients
allergic to local anesthetics.
Methods of closed reduction
Reduction of displaced fractures of the distal
radius has been based on two approaches: (1)
direct manipulation of the fracture fragments, and
(2) indirect fracture reduction with longitudinal
traction.
Manual reduction
The technique of direct manipulation of the
fracture with disimpaction of the distal fragment
before reduction has been attributed to Sir Robert
Jones [30]. It requires an assistant to provide
countertraction on the arm above the elbow
(Fig. 3). The first step is to disimpact the fracture
by increasing the initial deformity. Reduction then
is obtained with the opposite force to the one
responsible for the fragment displacement (mech-
anism of injury). For Colles fractures, therefore,
while traction is maintained the surgeon manipu-
lates the distal fragment into a volar and ulnar
direction with the opposite hand applying coun-
terpressure on the shaft fragment. The final
maneuver is to lock the fracture by placing the
patient’s hand and distal fragment into pronation.
The hand thereafter is allowed to rest without
support to assess the stability of the reduced
fracture clinically. Smith fractures, which present
with increased volar tilt, shortening, and pro-
nation of the distal fragment, are reduced with
Fig. 3. Technique of manipulative reduction of dorsally
displaced extra-articular bending fractures. (A) The
surgeon uses both hands to stabilize the forearm,
hand, and wrist while the fracture deformity is increased
by extending the wrist. (B) While traction is maintained,
the distal fragment is manipulated in a volar and ulnar
direction. (C) The fracture is locked in place, and (D) the
patient’s hand and fracture fragment is rotated into
slight pronation.
longitudinal traction, extension, and supination
maneuvers.
Longitudinal traction
This technique, initially popularized by Böhler
[31,32] during the 1920s, is based on strong
longitudinal traction applied to the patient’s
thumb and digits against a fixed and flexed elbow,
while the fracture is manipulated directly by the
surgeon. This method, which requires at least one
assistant but often two, was simplified by the
introduction of metallic finger traps by Caldwell
in 1931 [33]. The hand now could be suspended
with a counterweight over the upper arm, pro-
viding continuous longitudinal traction without
the need of assistants (Fig. 4). Although length,
distal radioulnar congruency, and ulnar inclina-
tion are invariably achieved, restoration of volar
tilt requires an additional palmarly directed force
by translating the hand volarly, as advocated by
Agee [34]. This displaces the capitate palmarly,
which in turn volarly rotates the scaphoid and
lunate, effectively forcing the distal fragment into
flexion (Fig. 5). A similar observation was re-
ported by Gupta in 1991 [35], in which, with
careful modeling of the cast with the wrist in
neutral or slight extended position, the same effect
was obtained with a low incidence of fracture re-
displacement. Agee [36] further advocated radio-
ulnar translation to realign the distal fragment
with the radial shaft in the frontal plane. This is
controlled by tension on the soft tissue hinge of
the first and second dorsal compartment. For
adequate reduction in the frontal plane it is
important to restore the anatomic relationship
of the sigmoid notch and the ulnar head. The
application of a dorsopalmar reduction force to
restore volar tilt should be kept in mind, because
it offers better anatomic restoration with immo-
bilization of the hand in a more physiologic and
functional position.
Cast immobilization
Despite the widespread acceptance of cast
immobilization, questions remain regarding the
optimal position, the duration of immobilization,
and the need to extend the cast above the elbow.
Having reduced the fracture, the author prefers to
immobilize initially all distal radius fractures in
a sugar tong splint that is maintained for the first
2–3 weeks (Fig. 6). Its advantages are that the
splint is applied easily while the upper extremity is
 DISTAL RADIUS FRACTURES: CLOSED MANIPULATION, CASTING 311

Fig. 4. (A) Finger trap-traction with the hand suspended and counterweight around the upper arm. Notice C-arm for
fluoroscopic control. (B) Following disimpaction through continuous traction the distal fragment can be manipulated
easily into the desired final position.

still suspended with the finger trap traction, and as
the cast sets, the hand can be translated palmarly
and placed in the definitive position of immobili-
zation. Because the U part of the splint comes
around the elbow, the sugar tong controls forearm
rotation and therefore efficiently maintains the
desired position of pronation or supination ac-
cording to the fracture type. Furthermore, the
sugar tong splint immobilizes the distal radioulnar
joint, and patients have less pain as compared
with those immobilized in a short arm cast.
Colles fractures are immobilized initially in
15( of palmar flexion, 10(–15( of ulnar devia-
tion, and slight pronation (25() for the first 2
weeks. To maintain a stable reduction it is
imperative to follow the details of the three-point
contact casting technique described by Charnley
[37] (Fig. 7). This implies the application of two
points of contact proximally and distally to the
fracture on the side of the concavity of the initial
angulation, and a counterpoint of contact at the
fracture level on the convexity of the initial
angulation. A slight bend to the splint or cast
(10(–15( and slight ulnar deviation) places the
soft-tissue hinge (periosteum and overlying
tendons) under tension, provided that the oppo-
site cortex has good contact (tension-band prin-
ciple). For a Colles type fracture, the counterpoint
or fulcrum (definition: point on which a lever
turns) is the volar cortex (Fig. 8). If reduction of
the volar cortex is anatomic without overlapping
of the fracture edges and the dorsoradial soft
tissue hinge is maintained under tension, the
chances of secondary displacement are minimal.
With increasing osteoporosis, however, a greater
amount of settling and shortening is to be
expected.
For the first 2 weeks the sugar tong splint is
maintained and follow-up radiographs are per-
formed 3, 7, and 12 days following reduction; this
enables detection of early loss of reduction and
whether or not settling and residual deformity is
acceptable. During the first 2 weeks the initial
splint should be adapted and remolded as soon as
soft tissue swelling decreases. This is achieved with
tighter wrapping of the splint with elastic ban-
dages at the time of the radiographic controls. In
this way a continuous and sufficient pressure
is maintained throughout the early postreduc-
tion period, reducing the possibility of secondary
312
Fig. 5. (A) Longitudinal traction with finger traps can
restore skeletal length. (B,C) Restoration of the normal
volar tilt of the distal radius articular surface, however,
may require palmar translation force of the mid-carpus.
(Courtesy of Hand Biomechanics Lab, Sacramento,
California; with permission)
displacement. At 2 weeks the splint is changed to
a short forearm cast for another 3–4 weeks, taking
care to maintain the three-point contact principle,
avoiding bulky padding of the cast.
Smith (or reversed Colles fractures) require
20( of dorsiflexion and 40( of supination to
maintain a stable reduction. Because the prona-
tory deformity of the distal fragment is always
present, above-elbow fixation to control forearm
Fig. 6. Technique of application of the sugar tong
splint. Notice minimal padding using thin layer of felt.
The splint is wrapped with elastic bandages while the
cast begins to set.
FERNANDEZ
Fig. 7. Schematic representation of the three-point
contact cast. If the volar cortex is reduced perfectly
(compression side), the dorsoradial soft tissue hinge is
maintained under tension with slight flexion and ulnar
deviation of the hand.
rotation is mandatory for the first 4 weeks
(Fig. 9).
Duration of immobilization
Most well reduced extra-articular fractures
heal by 4–5 weeks after injury [38]. Wahlström,
using 99Tc bone scans, observed well advanced
new bone formation by 28 days after injury. He
suggested that little additional immobilization is
required beyond this point [39]. In contrast,
Kristiansen et al observed early trabecular healing
39  2 days after fracture, with initial cortical
bridging at 50  3 days [40].
In the author’s experience, impacted and
minimally displaced fractures should be immobi-
lized for 3–4 weeks, and displaced fractures with
increasing comminution for 6 weeks (2–3 weeks in
a sugar tong and 3–4 weeks in a short arm cast)
(Fig. 10). Thereafter a protective removable wrist
orthesis is worn by the patient for an additional
month while active range of motion exercises are
begun. During that month the patient is weaned
progressively from the brace.
During the period of immobilization and also
during the period of weaning from the splint, all
patients are instructed to keep their fingers mo-
bile by performing the six-pack exercises as
 DISTAL RADIUS FRACTURES: CLOSED MANIPULATION, CASTING 313

Fig. 8. (A) Dorsally displaced extra-articular bending fracture with dorsal metaphyseal comminution. (B) A good
reduction was obtained in axillary block anesthesia. Notice anatomic reduction of the volar cortex. (C) At 12 days,
reduction is stable and a short cast was maintained for 6 weeks. (D) Roentgenograms at 6 weeks showing the fracture
healed with minimal dorsal settling and shortening. (E) Follow-up radiographs at 1.6 years reveal a remodeled fracture
in acceptable position. The patient had pain-free full wrist range of motion.

popularized by Dobyns [41] and by active elbow Summary

and shoulder mobilization at least three times
Closed reduction and cast treatment of distal
a day. Physiotherapy measures are indicated
radius fractures renders satisfactory results in
solely for those patients who have trouble re-
fractures that are reducible and stable and do
storing joint motion and forearm rotation follow-
not re-displace in plaster in the first 2 weeks
ing cast removal.
314 FERNANDEZ

Fig. 9. (A) Smith fracture with metaphyseal comminution and rotational malalignment. (B) Roentgenograms following
anatomic reduction that was maintained for 6 weeks in an above-elbow cast with the hand in dorsiflexion and mid-
supination (bottom). (C) Radiographs at 3 months show an excellent radiographic result.

following reduction [10,12]. Intra-articular and
unstable fractures have a high risk for re-displace-
ment in plaster [11] and therefore represent
a contraindication for cast treatment. A fracture
that re-displaces in plaster despite perfect casting
technique is most probably an unstable type that
requires skeletal fixation. A fracture that re-
displaces in a non-molded, loose, or over-padded
cast because of insufficient technique is, however,
in the author’s view, the only clinical situation in
which re-manipulation is worth the effort [8].
The tolerable amount of residual deformity has
been radiographically defined by Fourrier et al in
an analysis of 64 malunions of the distal radius
and correlated the functional impairment with the
residual deformity of the distal radius. They
concluded that the lower limits of deformity, at
which symptoms are likely to be present, are
 DISTAL RADIUS FRACTURES: CLOSED MANIPULATION, CASTING 315

Fig. 10. (A) Radiographs before and after closed reduction of a dorsally displaced distal radius fracture. Notice flexion
and ulnar deviation of the wrist. (B) At 4 weeks the wrist was brought to neutral position with careful dorsal molding of
the cast. (C) Fracture healed at 6 weeks showing perfect restoration of the wrist anatomy.

a radial deviation of 20(–30(, a sagittal tilt of
10(–20(, and a radial shortening of 0–2 mm [42].
In addition, experimental evidence suggests that
a sagittal tilt of 20(–30( should be viewed as
a pre-arthrotic condition [13,14,43]. Although
these figures are useful for decision making,
acceptance of deformity when treating fractures
conservatively varies individually according to
the age, osteoporosis, and functional demands
of the patient. Anatomic restoration, however,
should remain the primary goal of conservative
management.
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