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BOAST Guidelines
BOAST
Hand

The Management of Distal Radial Fractures

This BOAST guideline provides evidence-based standards for the initial evaluation, anaesthesia, reduction, surgical indication and timing, and rehabilitation pathways for adult distal radius fractures.

Key standards

  • ›Immediate baseline neurovascular assessment with explicit focus on median nerve function.
  • ›Prompt closed reduction for displaced fractures using adequate anaesthesia, preferentially IVRA (Bier block) or regional blocks rather than haematoma block.
  • ›Post-reduction immobilization in a below-elbow plaster slab avoiding extreme wrist flexion to minimize carpal tunnel pressures.
  • ›Obtain mandatory post-reduction orthogonal radiographs to confirm restoration of alignment.
  • ›Review non-operative cases in fracture clinic within 1-2 weeks with interval plain radiographs to assess for early loss of reduction.
  • ›CT imaging indicated pre-operatively for complex, multi-fragmentary intra-articular fractures.
  • ›Operative fixation for intra-articular fractures should be completed within 72 hours of injury.
  • ›Operative fixation for extra-articular fractures should be performed within 7 days of presentation.
  • ›Promote early active finger, thumb, and shoulder motion to prevent joint stiffness and swelling.
  • ›Provide bone health and secondary fragility fracture screening for all patients aged 50 years and older.

Introduction

Fractures of the distal radius are among the most frequently encountered injuries presenting to acute trauma services, occurring across all adult age groups from low-energy fragility falls to high-energy trauma. The primary objective of treatment is the restoration and optimisation of hand and wrist function while minimising complications and avoiding unnecessary intervention.

Initial Assessment and Emergency Care

  • Perform and document an immediate neurovascular evaluation, paying explicit attention to median nerve integrity.
  • Obtain standard orthogonal posteroanterior (PA) and lateral radiographs of the wrist.
  • Displaced fractures should be reduced as soon as safely achievable, particularly when neurovascular compromise, severe skin tenting, or marked deformity is present.
  • Analgesia and anaesthesia for manipulation must be robust and safe; intravenous regional anaesthesia (Bier block) or regional nerve blocks administered by trained personnel are strongly recommended over simple haematoma blocks due to superior pain relief and reduction quality.
  • Following manipulation, immobilise the wrist in a well-moulded below-elbow slab avoiding extreme flexion or ulnar deviation (Cotton-Loder position) to prevent median nerve compression in the carpal tunnel.
  • Repeat check radiographs immediately following manipulation and confirm restoration of acceptable alignment.

Fracture Clinic Review and Imaging

  • Patients managed non-operatively must be reviewed in an acute fracture clinic within 1 to 2 weeks of injury.
  • Check radiographs should be obtained at this initial review to detect early secondary displacement before the fracture consolidates.
  • Computed tomography (CT) is recommended when planning operative management for complex intra-articular fractures or when articular comminution and step-off cannot be adequately resolved on plain radiographs.

Surgical Indications and Timing

  • Surgical stabilization is indicated for fractures failing acceptable anatomical parameters (dorsal tilt >10–20°, radial shortening >3 mm, or articular step-off >2 mm) in physiologically active patients, or for unstable fracture patterns.
  • Timing thresholds:
    • Intra-articular distal radius fractures requiring operative intervention should ideally undergo surgery within 72 hours of injury.
    • Extra-articular fractures requiring operative fixation should undergo surgery within 7 days of injury (and no later than 14 days post-injury if delayed loss of position occurs).
  • Choice of fixation (e.g., volar locking plate, K-wire fixation, or external fixation) should be tailored to patient functional demands, bone quality, and fracture anatomy in light of trial evidence (such as DRAFFT).

Rehabilitation and Secondary Prevention

  • All patients must receive early instructions on immediate active mobilisation of uninvolved joints (fingers, thumb, elbow, and shoulder).
  • Following definitive cast removal or stable internal fixation, structured rehabilitation pathways and hand therapy should be available for patients who develop stiffness or complex regional pain syndrome (CRPS).
  • All patients aged 50 years and older presenting with low-energy distal radius fractures must undergo assessment for secondary bone protection (falls assessment and osteoporosis screening/DEXA referral).

Exam-tested points

  • ›Acceptable closed reduction parameters for non-operative management: dorsal tilt <10°, radial inclination >15°, intra-articular step-off <2 mm, and radial shortening <3 mm.
  • ›DRAFFT Trial: Percutaneous K-wire fixation vs. volar locking plates (VLP) in dorsally displaced fractures demonstrated no significant difference in PRWE (Patient-Rated Wrist Evaluation) functional scores at 12 months or 5 years, though VLP showed earlier short-term recovery at higher implant costs.
  • ›Surgical timing standards: BOAST/NICE recommend fixation within 72 hours for intra-articular fractures and within 7 days for extra-articular fractures.
  • ›Avoid the historical Cotton-Loder position (excessive flexion and ulnar deviation); extreme flexion increases carpal canal pressure and can precipitate acute median nerve compression or carpal tunnel syndrome.
  • ›Anaesthetic technique: BOAST and BSSH guidelines highlight intravenous regional anaesthesia (IVRA/Bier block) as providing superior muscle relaxation and reduction compared to local haematoma block.
  • ›Soong grading criteria on lateral wrist radiographs for volar plate position: plates placed distal to the 'watershed line' (Soong Grade 2) carry a high risk of flexor pollicis longus (FPL) tendon irritation and delayed rupture.
  • ›Secondary prevention: A distal radius fracture in patients >50 years represents a sentinel fragility fracture requiring bone health workup (FRAX score, DEXA, and falls risk assessment).
Official BOA source
Read the official guideline

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