Distal Radius Manipulation

Indications & acceptable position

• Displaced distal radius fracture (classically dorsally angulated and impacted — the "dinner-fork" deformity) causing unacceptable angulation, shortening or articular step-off on the initial X-ray.
• Principles of an acceptable position rather than fixed numeric cut-offs: minimal dorsal angulation of the distal fragment relative to the shaft, minimal radial shortening, restoration of radial inclination and length, and a congruent, minimally-stepped articular surface. Thresholds vary between guidance documents and by patient age/function — the BOA/BSSH Blue Book process itself notes there is insufficient evidence to fix universal radiological cut-offs against patient-rated outcome, so use local departmental/orthopaedic criteria and clinical judgement for your patient.
• Manipulate promptly — swelling and fracture "setting" make later manipulation harder and less comfortable.

Contraindications & cautions

Analgesia options

• Haematoma block — simple, fast, first-line for most ED manipulations (technique below). Maximum lidocaine 1% dose is 3 mg/kg (plain, without adrenaline).
• Bier's block (IV regional anaesthesia) — an RCEM-approved technique for distal forearm fractures giving more complete anaesthesia and muscle relaxation than a haematoma block; requires two trained clinicians (one performing the reduction, one dedicated to the tourniquet/monitoring/drug safety) and a functioning double-cuff tourniquet. Follow the RCEM best-practice guidance in full before attempting.
• Procedural sedation is an alternative where haematoma block or Bier's block are unsuitable or have failed, but adds a monitoring and recovery burden.
• Entonox for the manipulation moment itself is a useful adjunct regardless of the block used.

Equipment

Haematoma block technique

1. Confirm the fracture and plan the injection site

   Review the X-ray; identify the dorsal fracture haematoma, usually most easily accessed dorsally 2–3 cm proximal to the fracture line.

2. Aseptic technique

   Clean the skin thoroughly — you are injecting directly into a fracture haematoma, and infection here risks osteomyelitis.

3. Needle into the haematoma

   Advance the needle into the fracture site. Aspirate first — free flow of dark, non-clotting blood confirms haematoma placement before you inject.

4. Inject

   Instil lidocaine 1% slowly, to a maximum of 3 mg/kg plain. Allow several minutes for onset before manipulating — rushing the manipulation before the block has taken effect is a common cause of a painful, poorly-tolerated reduction.

   LAST rescue — AAGBI algorithm ↗

Dinner-fork deformity & reduction direction

Manipulation technique

1. Position & counter-traction

   Elbow flexed to 90°, an assistant or finger traps providing counter-traction against the upper arm.

2. Traction

   Apply firm, steady longitudinal traction through the hand/fingers to disimpact the fracture.

3. Exaggerate the deformity

   Briefly increase the dorsal angulation while under traction — this helps disengage the impacted dorsal cortex before correction.

4. Correct — palmar flexion and ulnar deviation

   With traction maintained, flex the wrist palmarly and deviate ulnarly to restore alignment, moulding the distal fragment back into position with thumb pressure over the dorsum.

5. Hold and splint

   Maintain the corrected position while an assistant applies a moulded backslab — do not let go until the plaster has set enough to hold the reduction.

Immobilisation & post-reduction checks

• Apply a moulded dorsal (or well-moulded) below-elbow backslab with the wrist in slight flexion and ulnar deviation as achieved on reduction, avoiding excessive flexion which risks median nerve compression.
• Do not complete a full circumferential cast acutely — swelling risk; a backslab allows expansion.
• Post-reduction X-ray before the patient leaves the department to confirm acceptable position.
• Re-check the neurovascular exam (especially median nerve/palmar sensation) after manipulation and casting.
• Written cast-care advice: elevate, move fingers, return if the cast becomes tight, painful, or fingers become pale/numb/blue.

Follow-up

• Refer to fracture clinic per local pathway — typically within a week for repeat X-ray, cast check, and a decision on definitive management (continued cast vs surgical fixation) if the position has been lost.
• Document indication, analgesia/block used and dose, manipulation performed, pre- and post-reduction X-ray findings, neurovascular checks, and safety-netting advice given.

References