Distal radius and ulna fractures: clinical guidelines

List of Abbreviations

EFA – external fixation apparatus

AO – Association for Osteosynthesis

VTE – venous thromboembolism

RH – radial head

DKP – diaphysis of the forearm bones

DMELK – distal metaepiphysis of the radius

DOKP – distal forearm bones

RTA – road traffic accident

CT – computed tomography

HDL – high-density lipoproteins

LDL – low-density lipoproteins

PT – physical therapy

Ministry of Health of the Russian Federation – Ministry of Health of the Russian Federation

MRI – magnetic resonance imaging

LMWH – low molecular weight heparin from the heparin group (B01AB)

NSAIDs – non-steroidal anti-inflammatory and antirheumatic drugs

PPFA – proximal forearm bones

UFH – unfractionated heparin (sodium heparin**) from the heparin group (B01AB)

SWD – surgical wound debridement

SCT – spiral computed tomography

RF – risk factors

PRM – physical and rehabilitation medicine

FS – functional status

Surgical antibiotic prophylaxis

ЧЭНС – transcutaneous electrical nerve stimulation for peripheral nervous system disorders

LCP – locking compression plate

MIPO – minimally invasive plate osteosynthesis

ORIF – open reduction internal fixation

Terms and Definitions

Internal fixation device – an orthopedic implant implanted beneath the patient's skin that connects bone fragments in the treatment of fractures, deformities, or nonunions.

Bone fragment – a portion of bone separated as a result of trauma, surgery, or a destructive process.

External fixation device (EFD) – an orthopedic device comprising an implant (a transosseous or extracorporeal element protruding through the skin, reaching or embedded in the bone) and an external (non-implantable) frame that connects bone fragments via transosseous elements during the treatment of fractures, nonunions, or gradual segment lengthening (correction of deformity).

Load – mechanical force applied to a limb, bone, and fixation system during treatment, typically recurring with constant periodicity (cyclically).

Fixation – a state in which relative or complete immobilization of fragments is achieved.

Fixation stability – resistance of the system to external loads, allowing it to maintain the constancy of the mutual orientation of fragments and the optimal distance between them.

Absolute stability – absence of fragment micromotion under conditions of anatomical reduction and interfragmentary bone compression following their fixation

Relative stability – controlled micromotion in the fracture zone that does not prevent indirect bone healing with callus formation and is achieved by splinting the fracture zone with restoration of axis, segment length, and elimination of rotational displacement of fragments.

Migration of fixation elements – loss of the optimal position of fixation elements due to bone resorption around them, occurring when allowable cyclic loads or their number are exceeded, or due to errors in the surgical technique of implanting the element into the bone (within the context of this topic).

Fracture union – mutual connection of fragments by living bone tissue as a result of the successful completion of reparative regeneration.

Delayed union / Nonunion – changes in the reparative regeneration of bone tissue leading to a decrease in its rate, cessation, or formation of a callus insufficient to perform mechanical function.

Post-traumatic deformity – fracture union with a disturbance of spatial relationships between fragments, including axial and rotational ones.

Contracture – restriction of the range of motion in a joint.

Epiphyseolysis — disruption of the integrity of the growth cartilage of a tubular bone due to mechanical force, accompanied in some cases by displacement of the epiphysis.

Osteoepiphysiolysis – disruption of the integrity of the growth cartilage of a tubular bone combined with a metaphyseal fracture.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Distal forearm fractures (DFF) are a concept encompassing isolated fractures of the distal radial metaphysis (DRM) or distal ulnar metaphysis, as well as fractures of the distal parts of both forearm bones. These fractures represent a disruption of the integrity of the forearm bones in the area of the distal metaphysis, including growth plates in children and adolescents due to trauma. According to the number of fragments, DFFs are divided into simple and comminuted.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

DFFs occur as a result of an external traumatic agent. According to the injury mechanism, direct and indirect impact are distinguished. The indirect trauma mechanism is characterized by the application of the traumatic force at a distance from the fracture site. In the direct trauma mechanism, the force is applied directly to the fracture site [1]. The vast majority of DFFs occur due to an indirect mechanism. In 75% of cases, the cause of this injury is a fall from standing height [2]. According to the trauma energy, such injuries are classified as low-energy. The remaining proportion of DFFs results from road traffic accidents, falls from a height, and sports activities. This type of trauma mechanism leads to high-energy injuries. Fractures resulting from high-energy trauma are multi-comminuted or segmental [1]. In elderly patients, forearm shaft fractures frequently occur against the background of reduced bone mineral density [3].

1.3 Epidemiology of the Disease or Condition

DRM fractures are the most frequent upper extremity injury. One-sixth of patients with skeletal injuries seek medical care due to a DRM fracture [1]. This injury accounts for 7.5% of all fractures and 15.7% of upper extremity fractures. Furthermore, in 31% of cases, a DRM fracture is combined with a fracture of the ulnar styloid process [4]. Isolated fractures of the distal ulna are relatively rare [5].

Women over 65 years of age are most frequently victims of this injury, which is associated with age-related decline in bone density. In this age group of patients, DRM fractures account for about 18% of all fractures [6].

1.3.1 Specific features in children and adolescents

Forearm bone fractures in children are the most frequent trauma and rank first among extremity injuries, accounting for up to 45% of all fractures in the pediatric population and 62% of upper extremity fractures [7-10]. Fractures of the lower third of the forearm account for 75% to 84% of all forearm fractures, the middle third – from 15% to 18%, and the upper third of the forearm – from 1% to 7% [10-13]. Meanwhile, distal radius fractures account for 20% to 35% of all fractures in children [14, 15], and the distal radial growth plate accounts for up to 15% of all distal radius fractures [16].

The overall incidence of distal forearm fractures in children is approximately 738 per 100,000 population per year. 81% occur in children older than 5 years, with the peak incidence of distal forearm fractures occurring at 12–14 years of age in boys and 10–12 years of age in girls. The most common (>50% of all fractures) fracture type is the greenstick fracture of the radius [17].

1.4 Features of Coding the Disease or Condition

S52.5 – Fracture of lower end of radius.

S52.50 – Closed fracture of lower end of radius.

S52.51 – Open fracture of lower end of radius.

S52.6 – Combined fracture of lower ends of ulna and radius.

S52.60 – Closed combined fracture of lower ends of ulna and radius.

S52.61 – Open combined fracture of lower ends of ulna and radius.

S52.8 – Fracture of other parts of forearm.

S52.9 – Fracture of unspecified part of forearm.

S54.0 – Injury of ulnar nerve at forearm level.

S54.1 – Injury of median nerve at forearm level.

M89.0 – Algoneurodystrophy.

1.5 Classification of the disease or condition

According to the trauma mechanism, DFFs are subdivided into flexion fractures (Smith), in which the distal fragment is displaced in the palmar direction, and extension fractures (Colles), in which the distal fragment is displaced dorsally.

To accurately determine the anatomical location of a fracture, its center must be identified. For a simple fracture, the center is the midpoint of the oblique or spiral fracture line; for fractures with a wedge, it is the widest part of the wedge or the midpoint of the fragmented wedge after reduction; for complex fractures, the center is determined after reduction with restoration of bone length as the midpoint between the proximal and distal borders of the fracture.

Diagnosis coding begins with determining the anatomical localization of the fracture: bone and segment. According to the latest revision of the AO universal fracture classification, radius and ulna fractures are coded separately. All forearm bone fractures correspond to codes 2R (radius) and 2U (ulna). DFF is coded as 2R3 or 2U3, respectively. Next, the morphological characteristics of the fracture are determined. This involves identifying the fracture type, group, and subgroup. All fractures are subdivided into 3 types: A, B, and C.

DFFs are divided into the following groups:

2R3A – extra-articular distal radius fracture:

2R3A1 – avulsion fracture of the radial styloid process;

2R3A2 – simple extra-articular distal radius fracture;

2R3A3 – extra-articular distal radius fracture with a wedge-shaped fragment or comminuted.

2U3A – extra-articular distal ulna fracture:

2U3A1 – avulsion fracture of the ulnar styloid process;

2U3A2 – simple extra-articular distal ulna fracture;

2U3A3 – complex extra-articular distal ulna fracture.

2R3B – partial intra-articular distal radius fracture:

2R3B1 – with fracture line in the sagittal plane;

2R3B2 – with fracture line in the frontal plane with dorsal displacement of fragments;

2R3B3 – with fracture line in the frontal plane with volar displacement of fragments.

2R3C – complete intra-articular distal radius fracture:

2R3C1 – simple intra-articular and simple metaepiphyseal fractures;

2R3C2 – simple intra-articular and complex metaepiphyseal fractures;

2R3C3 – complex intra-articular and simple or complex metaepiphyseal fractures [18].

Fernandez classification of DRM fractures is based on the mechanism of injury. The author distinguishes 5 fracture types:

Type 1: flexion fracture of the distal metaphysis and epiphysis of the forearm bones (DMEFB)

Type 2: shearing intra-articular fracture of the DMEFB

Type 3: compression fracture of the articular surface of the DMEFB

Type 4: marginal, avulsion fractures combined with carpal dislocation

Type 5: high-energy combined fracture of the DMEFB (combination of types 1, 2, 3, and 4) [1].

For open forearm bone fractures, the classification by R.B. Gustilo, J.T. Anderson (1976) [19] as modified by R.B. Gustilo et al. (1984) [20] is used.

Type I – open fracture, wound mildly contaminated, wound size less than 1 cm.

Type II – open fracture, wound greater than 1 cm and less than 10 cm in length without extensive soft tissue damage, flaps, or skin avulsion.

Type IIIA: open fracture with soft tissue coverage of the bone fragments, no periosteal stripping despite extensive soft tissue damage or the presence of flaps, or resulting from high-energy trauma regardless of the wound size.

Type IIIB: open fracture with extensive soft tissue defect, periosteal stripping, and comminuted fracture pattern, frequently accompanied by significant wound contamination.

Type IIIC: open fracture complicated by major vascular injury requiring surgical reconstruction, regardless of the extent of soft tissue damage.

1.5.1 Specific features in children and adolescents

For fractures in the region of the distal epiphyseal growth plates, the most widely used classification is the one proposed by Canadian orthopedists R.B. Salter and W.R. Harris (SH) in 1963 [21]:

• SH I – through the growth plate (5%);

• SH II – through the growth plate and metaphysis (75%);

• SH III – epiphyseal fracture (10%);

• SH IV – metaepiphyseal fracture extending through the growth plate (10%);

• SH V – compression injury of the growth plate.

A special type of injury to the distal forearm is the Galeazzi fracture-dislocation [22–24]. In skeletally mature children, this injury includes a fracture of the distal metadiaphysis of the radius combined with dislocation of the ulnar head at the distal radioulnar joint (DRUJ). The dislocation occurs as a result of damage to the soft-tissue stabilizers of the DRUJ (the triangular fibrocartilage complex (TFCC), interosseous membrane, etc.) [24, 25]. In children with open growth plates, energy transmitted through the DRUJ more frequently leads to a fracture in the physeal region of the distal ulna rather than injury to the ligamentous apparatus, due to the fact that children's growth plates are biomechanically weaker than the ligamentous stabilizers of the DRUJ. This type of fracture is the pediatric equivalent of a Galeazzi injury [8, 24–26].

1.6 Clinical presentation of the disease or condition

The clinical presentation of distal forearm fractures is characterized by severe pain at the fracture site, tenderness upon palpation and axial loading. If fragment displacement is present, shortening of the forearm, visible angular or bayonet deformity at the fracture site, and abnormal mobility of bone fragments are detected.

If a distal forearm fracture is suspected, all patients must be transferred to a medical facility to verify the diagnosis and provide appropriate treatment.

Complaints: pain in the lower third of the forearm, abnormal mobility, deformity at the fracture site, pain in wound areas (in open fractures), and tenderness upon movement in the wrist joint and hand joints.

Anamnesis: history of trauma; the patient describes a characteristic mechanism of injury. Forearm fractures most commonly occur as a result of a fall onto the hand. In cases of high-energy trauma, attention must be paid to concomitant soft tissue injuries [1].

Objective status: edema of the lower third of the forearm and hand, limitation of active and passive movements due to severe pain syndrome, visually determined forearm deformity at the fracture level, tenderness upon palpation, crepitus of bone fragments, and abnormal mobility of the forearm. In cases of pronounced edema or significant fragment displacement, signs of median nerve neuropathy may develop [27].

1.6.1 Specific features in children and adolescents

In younger children, minor edema and limitation of active and passive movements of the upper extremity may be the only clinical signs; minimal clinical manifestations do not rule out subperiosteal fractures without displacement [14, 15].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition:

• history data: indication of a characteristic mechanism of upper extremity trauma (fall, motor vehicle accident, direct blow to the segment, etc.)

• physical examination findings: impaired function of the injured segment, local swelling and tenderness in the trauma region (pain exacerbated by axial loading), presence of abnormal mobility and/or fragment crepitus

• instrumental examination data: radiographic signs of a fracture based on X-rays of the ulna and radius including adjacent joints in 2 projections. Additional computed tomography (CT) of the bone may be performed as prescribed by the on-duty or attending orthopedic trauma surgeon to clarify the nature of the fracture and determine the degree of fragment displacement, especially in fracture-dislocations and when an intra-articular fracture component is suspected.

2.1 Complaints and Anamnesis

In most cases, patients present with complaints described in Section 1.6 "Clinical Presentation"

2.2 Physical Examination

Physical examination findings are described in Section 1.6 "Clinical Presentation"

• Evaluation of the following parameters by an orthopedic trauma surgeon is recommended to be performed no later than 1 hour after admission to the inpatient hospital, with the results mandatorily recorded in the medical documentation for diagnostic purposes:

- assessment of somatic status;

- visual and palpation assessment of local status [28, 29].

LEL 5Grade of Recommendation C (Level of Evidence – 5).

- measurement of blood pressure on peripheral arteries;

- general thermometry;

- assessment of the risk of venous thrombosis and pulmonary embolism (Appendix 15.2) [30].

LEL 5Grade of Recommendation C (Level of Evidence – 5).

• When making a decision to perform surgical treatment for a distal forearm fracture, it is recommended to collect anamnesis and perform a physical examination to identify risk factors and cardiovascular diseases [31, 32].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comment: Risk factors for cardiovascular diseases include: arterial hypertension, smoking, dyslipidemia (elevated total cholesterol >4.9 mmol/L and/or LDL cholesterol >3 mmol/L and/or HDL cholesterol <1.0 mmol/L in men, <1.2 mmol/L in women, and/or triglycerides >1.7 mmol/L), diabetes mellitus, and a family history of cardiovascular disease at a young age (<55 years for men and <65 years for women) [14]. Established cardiovascular disease is defined as: ischemic heart disease, cerebrovascular disease, peripheral atherosclerosis, chronic heart failure, pulmonary hypertension, valvular heart disease, cardiomyopathies [32, 33].

• All patients referred for elective surgical treatment of a distal forearm fracture are recommended to undergo an assessment of the risk of perioperative cardiovascular complications, taking into account the type of planned surgical treatment regardless of the presence of comorbid pathology [31, 34].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: When surgical treatment is performed for emergency (<6 hours) and urgent (6–24 hours) indications, preoperative risk assessment is not performed.

Minor orthopedic surgeries are associated with a low risk of cardiovascular complications (30-day risk of myocardial infarction or cardiovascular death after surgery is less than 1%). Major orthopedic surgeries are associated with an intermediate (moderate) risk of cardiovascular complications (30-day risk of myocardial infarction or cardiovascular death after surgery is 1–5%) [35].

• To assess the risk of perioperative cardiovascular complications in adult patients, it is recommended to use a special algorithm (Appendix B2) [34, 36].

BMR BLEL 3Level of recommendation validity B (level of evidence – 3).

• Elective surgical treatment of a distal forearm fracture is recommended without additional workup for patients whose cardiovascular complication risk is determined to be low. In patients with intermediate or high perioperative risk of cardiovascular complications, assessment of the patient's functional status is recommended to prevent potential complications [35, 37].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

2.3 Laboratory Diagnostics

• All adult patients diagnosed with a distal forearm fracture for whom surgical treatment is planned are recommended to undergo the following laboratory tests for diagnostic purposes:

- complete blood count;

- urinalysis;

- general-profile blood biochemistry test: determination of total bilirubin level in the blood, determination of aspartate aminotransferase activity in the blood, determination of aspartate aminotransferase activity in the blood, determination of urea level in the blood, determination of creatinine level in the blood, determination of total protein level in the blood, determination of glucose level in the blood;

- determination of main blood groups by the ABO system and determination of the D antigen of the Rhesus system (Rh factor);

- determination of hepatitis B virus surface antigen (HBsAg) in the blood;

- determination of antibodies to Hepatitis C virus in blood (Anti-HCV);

- determination of antibodies to Treponema pallidum in the blood;

- determination of antibodies of classes M and G (IgM, IgG) to human immunodeficiency virus HIV-1/2 and p24 antigen (Human immunodeficiency virus HIV 1/2 + Agp24) in the blood;

- coagulogram (screening hemostasis test);

- determination of the international normalized ratio (INR) [38, 39, 40].

QOE 3Level of Evidence A (reliability of evidence level – 3).

• When deciding on surgical treatment for a distal forearm fracture, it is recommended to test the level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the blood in cases of intermediate or high risk of cardiovascular complications and low functional status of the patient (see Appendix 15.3) [32, 35, 41, 42].

LEL 5Grade of Recommendation C (Level of Evidence – 5).

2.4 Instrumental Diagnostics

Comments: Performing wrist radiography is necessary to establish the diagnosis of a distal forearm fracture, determine the fracture pattern and degree of fragment displacement, rule out injury to the segment at other levels, and diagnose fracture-dislocations. In case of inconclusive findings for a distal forearm fracture, radiographs in oblique projections or comparative radiographs of the patient's healthy upper extremity may be performed.

In cases of high-energy trauma, it is recommended to perform radiography of the ulna and radius as well as hand radiography to rule out skeletal injury of the upper extremity at other levels.

After confirming a distal radius fracture using diagnostic imaging, the question of admitting the patient to an inpatient facility is addressed. The patient must be hospitalized if surgical treatment is planned. If conservative treatment is chosen, the patient may undergo closed manual reduction of bone fragments and upper extremity immobilization. The method of primary immobilization is described below in the section on conservative treatment.

If there are indications for surgery and the patient refuses inpatient treatment, the reason for refusal must be documented in the medical records with the signature of the patient or their legal guardians (in case of legally established incapacity of the patient).

- significant metaphyseal-epiphyseal fragmentation;

- angular deformity of 10 degrees or more;

- shortening of more than 5 mm;

- articular surface fragment displacement of more than 2 mm;

- dislocation or subluxation of the wrist [1].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: MSCT provides the orthopedic trauma surgeon with additional information on the fracture pattern, the degree of fragment displacement, and the severity of articular surface damage, thereby significantly facilitating the determination of indications for surgical treatment and improving the quality of preoperative planning.

• Echocardiography may be considered before planned surgical treatment of a distal radius fracture in patients with low functional status, elevated NT-proBNP levels, left ventricular systolic dysfunction, cardiomyopathies, heart valve diseases, newly detected heart murmurs, and suspected cardiovascular disease [35, 48, 49].

LEL 5Grade of Recommendation C (Level of Evidence – 5).

2.4.1 Specific features of instrumental diagnostics in children and adolescents

Comments: performing radiography of the ulna and radius capturing two joints is necessary to diagnose a distal forearm fracture in children, determine the type and pattern of the fracture, and the degree of fragment displacement. The appropriateness of X-ray examination should be based on the analysis of clinical examination data. The indication for X-ray examination is suspected forearm bone fracture. The main instrumental diagnostic method is radiography of the ulna and radius in 2 standard projections capturing the wrist and elbow joints. There are no contraindications to the examination. If there is no clear clinical localization of the injury (mainly applicable to younger children), radiography of the entire upper extremity in anteroposterior and oblique (three-quarter) projections must be performed.

• Forearm bone ultrasound in pediatric patients with distal forearm fractures is not recommended [8].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: according to domestic authors, ultrasound is not used in the diagnosis of acute forearm bone injuries due to its low informativeness compared to X-ray diagnostics. However, the advantage of this method is the absence of ionizing radiation. According to foreign authors, ultrasound is a highly sensitive but operator-dependent procedure for detecting distal forearm fractures. In any questionable situation, there remains a high need for standard radiography [51].

• CT and magnetic resonance imaging (MRI) are not used in the acute period of distal forearm injuries in children [52].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: Indications for performing CT and magnetic resonance imaging of the upper extremity, forearm bones, and wrist joint may include the need for differential diagnosis of conditions simulating traumatic injuries (osteomyelitis, pathologic fractures) [53].

2.5 Other Procedures

- Initial neurosurgeon consultation (examination): in case of nerve injury or suspected nerve injury and concomitant head injury;

- Initial consultation (examination) by a general surgeon: in case of suspected or objectively diagnosed concomitant abdominal and/or chest trauma;

- Initial consultation (examination) by a pediatric surgeon: in case of suspected or objectively diagnosed concomitant abdominal and/or chest trauma;

- Initial consultation (examination) by a neurologist: in case of nerve injury or suspected nerve injury and concomitant traumatic brain injury;

- Initial cardiovascular surgeon consultation (examination): in case of concomitant vascular injury or suspected vascular injury;

- Initial consultation (examination) by a pediatrician: in the presence of comorbid pediatric conditions (based on the child's medical history);

- Initial consultation (examination) by a general practitioner (internist): in the presence of comorbid internal medicine conditions (based on medical history) [54].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• If acute or unstable clinical conditions are identified, it is recommended to postpone elective surgical treatment of the distal radius fracture and arrange for the patient's transfer to a regional vascular center or specialized cardiology department to improve cardiac status and stabilize the patient's condition [35].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

To understand the mechanism of wrist fractures, one must keep in mind the three-column concept of distal radius structure. The lateral column includes the radial styloid process, the scaphoid fossa, and the corresponding part of the distal articular surface of the radius. The intermediate column consists of the medial half of the distal articular surface of the radius, the lunate fossa, and the sigmoid notch of the radius. The medial (ulnar) column includes the distal part of the ulna and the triangular fibrocartilage complex. Under normal conditions, the majority of the load is transmitted to the proximal forearm via the intermediate column. Nevertheless, the radial styloid process plays an important role in wrist stabilization, providing a bony buttress and serving as the attachment site for the radial collateral ligament of the wrist. When the hand is clenched into a fist, load transfer is redistributed from the intermediate to the ulnar column. Thus, all three columns participate in providing the full range of motion in the wrist joint [1, 55].

3.1 Conservative treatment:

• For patients with distal radius fractures upon admission to the hospital, the following minimum volume of care in the emergency department is recommended:

- ensuring thermal comfort for the patient;

- adequate pain management;

- immobilization of the injured upper extremity;

- correction of fluid and electrolyte disturbances [54, 69].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

- in incomplete fractures or fractures without fragment displacement;

- in displaced fractures where, after closed reduction, there are no signs of instability with acceptable residual deformation (radial shortening of less than 2 mm, dorsal angular displacement of the distal fragment of less than 10 degrees, no articular surface fragment displacement after reduction);

- in the presence of comorbid pathology that is a contraindication to elective surgical treatment;

- upon the patient's voluntary refusal of surgery [4].

Relative indications for conservative treatment are:

- extra-articular distal radius fractures with displacement, where a dorsal angular deformity of 10–20 degrees persists after reduction;

- fractures with radial shortening of about 2 mm;

- complex extra-articular fractures where, after reduction, displacement of a small extra-articular fragment persists while the remaining major fragments are in anatomical position and stable;

- distal radius fractures in elderly patients with dorsal fragment displacement of more than 20 degrees [4].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: Conservative treatment consists of immobilization from the proximal palmar crease to the upper third of the forearm in a mid-position between supination and pronation [4, 43, 56].

Immobilization of the injured upper extremity is performed using various types of fixing bandages (application of an immobilizing bandage for bone fractures). The type of bandage used depends on the patient's individual characteristics and the attending physician's preference. A plaster cast slab (application of a plaster cast for bone fractures) is most commonly used. Bandages made of synthetic materials, as well as various prefabricated rigid fixators, can also be used. The duration of fixation is approximately 5–7 weeks. During conservative treatment, staged X-ray examinations are necessary to diagnose potential secondary fragment displacement, which serves as an indication for surgical treatment [4].

Caruso et al. [56] conducted a randomized prospective study aimed at comparing the functional outcomes of conservative treatment in patients with distal radius fractures using short (from the proximal palmar crease to the upper third of the forearm) versus long immobilization casts (from the metacarpophalangeal joints to the middle third of the arm). According to the authors' findings, there are no statistically significant differences between the radiological and functional outcomes of patients in the studied groups; however, patients immobilized with the short cast experienced fewer complications related to elbow joint stiffness.

Comments: Closed manual reduction is performed under adequate anesthesia (local or regional). Closed manual reduction is recommended to be performed with the patient in the supine position, with the upper extremity abducted at the shoulder joint to 90 degrees and flexed at the elbow joint to 90 degrees. The arm is suspended by the fingers from a crossbar located at a height of 5–10 cm from the fingertips. Reduction of the fracture occurs under the weight of the arm's own gravity. To assess the position of the fragments after reduction, control radiography of the ulna and radius is performed in 2 projections. In case of unsuccessful closed manual reduction or with an unstable distal radius fracture with a tendency to displacement, percutaneous pinning of the fragments or osteosynthesis should be performed [4].

3.1.1 Specific features of conservative treatment in children and adolescents

• In pediatric patients with distal forearm fractures without fragment displacement, immobilization with a plaster splint (application of a plaster cast for bone fractures) is recommended [8, 9, 22, 50, 57, 58].

GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).

Comments: conservative treatment of distal forearm fractures in children is carried out by means of immobilization with a plaster splint from the metacarpophalangeal joints of the fingers to the upper third of the forearm for 3–5 weeks.

• In pediatric patients with displaced distal forearm fractures, closed reduction (reduction of bone fragments in fractures) and immobilization with a plaster splint (application of a plaster cast for bone fractures) are recommended [8, 9, 11, 22, 50, 57, 58].

GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).

Comments: conservative treatment of displaced distal forearm fractures in children is carried out using closed reduction and immobilization with a plaster splint from the metacarpophalangeal joints of the fingers to the middle third of the arm for 4–5 weeks. In injuries involving the distal physeal zones of the forearm bones, timely and complete correction of all displacement components must be performed, achieving an anatomically correct position of the bone fragments through closed reduction to prevent impairment of the normal growth and development of the forearm [57, 59]. Considering the risk of secondary displacement of bone fragments after soft tissue swelling subsides, control radiography of the forearm in two projections should be performed on days 5–7 [8, 9, 50].

Radiometric values of acceptable displacements in distal third forearm fractures (according to literature data) [59–64].

Children under 10 years

Children 10 years and older

Analgesia

• For the purpose of adequate analgesia in patients with distal radius fractures it is recommended to use multimodal analgesia for adults and children, taking into account age restrictions, which may include NSAIDs (from group M01A Non-steroidal anti-inflammatory and antirheumatic products), paracetamol**, gabapentinoids (ATC group code N02BF), and immediate-release opioids (ATC group code N02A) taking into account age restrictions in the instructions for medical use; if administration is impossible, monomodal analgesia [66–68, 142].

Adults – Levele of recommendation A (level of evidence – 2).

Children – Level of recommendation C (level of evidence – 5).

Comments: Multimodal analgesia (MMA) involves the use of several analgesic drugs (opioid and non-opioid) with different mechanisms of action and non-pharmacological interventions aimed at acting on peripheral and/or central parts of the nervous system [69]. Such a combination allows for more effective pain relief by enhancing the effects of various drugs, which in most cases leads to a reduction in the frequency of prescriptions and/or doses of opioid analgesics. Thus, MMA reduces the risk profile of each drug while providing synergistic pain control using different drug classes. Postoperative MMA may include psychotherapy, physical therapy, NSAIDs, paracetamol**, gabapentinoids (N02BF), regional anesthesia (single injection or placement of peripheral nerve catheters), local injections, and opioids [67, 70].

In modern scientific literature, authors emphasize the use of the lowest effective doses of opioids for the shortest possible period of time, avoiding extended-release opioids. As an adjuvant against the background of MMA for adult patients, a single administration of #dexamethasone** 1.25–20 mg IV before surgery (60 min before incision) can be used, which provides a significant reduction in pain syndrome [66].

It must be remembered that the duration of parenteral administration of most NSAIDs (ketorolac**, ketoprofen**, diclofenac**) is limited to two days, which requires timely switching of the patient to oral administration, changing the drug, or coordinating further use with the medical commission. The specific choice of local anesthesia method and medicinal products is made by the attending physician individually in accordance with the patient's characteristics, local protocols, and the equipment of the medical organization.

When prescribing analgesic therapy for children, a single dose should be chosen taking into account the child's weight and age. Preference should be given to analgesics with oral or rectal administration routes, avoiding intramuscular injections.

Recommended analgesic medications are listed in Appendices A3.1-A3.3

Surgical antimicrobial prophylaxis

• When performing surgical treatment in patients with closed distal radius fractures, it is recommended to carry out surgical antibiotic prophylaxis (SAP) of surgical site infections by a single preoperative administration of a systemic antibacterial drug in order to reduce the risk of infectious complications [71, 72].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments. In accordance with international clinical guidelines for the prevention of surgical site infections [71, 73], the objective of SAP is to create bactericidal concentrations of a systemic antibacterial drug in tissues exposed to microbial contamination during surgery to prevent surgical site infections. The need for SAP is determined by the surgical wound class of the upcoming operation: SAP is not required for "clean" surgical wounds not associated with the placement of orthopedic implants and metal structures. SAP should be performed: for clean-contaminated and contaminated surgical wounds; for "clean" surgical wounds involving the placement of orthopedic implants and metal structures. For infected ("dirty") wounds, SAP is not indicated; instead, antibiotic therapy is administered.

• In patients with distal radius fractures, first- and second-generation cephalosporins (I and II generation, ATC J01DB, J01DC) (cefazolin**, cefuroxime**) are recommended as the primary drugs for surgical antibiotic prophylaxis during surgical interventions in traumatology and orthopedics; as an alternative in case of intolerance to beta-lactam antibacterial drugs, glycopeptide structure antibacterial drugs (vancomycin**), lincosamides (#clindamycin**) [71]. The use of these medications is carried out taking into account age restrictions in the instructions for medical use.

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments. For patients with an unburdened allergic history and no significant risk factors for methicillin-resistant Staphylococcus carriage, first- and second-generation cephalosporins (cefazolin**, cefuroxime**) are used for SAP, administered intravenously between 30 and 60 minutes before skin incision. In case of intolerance to beta-lactam antibacterial drugs, a combination of vancomycin** with one of the fluoroquinolones (ATC J01MA) (ciprofloxacin**, #levofloxacin**), administered over at least 60 min with the start of intravenous infusion 2 hours before incision, or #clindamycin** should be prescribed. In case of significant risk factors for methicillin-resistant Staphylococcus (MRS) carriage, the SAP regimen should include systemic antibacterial drugs (ATC: J01) with anti-MRS activity (vancomycin**). In most cases, a single preoperative dose of a systemic antibacterial drug is sufficient for effective prophylaxis. For prolonged procedures (more than 3 h) or massive blood loss, an additional intraoperative dose of a systemic antibacterial drug (ATC: J01) should be administered (approximate timing of intraoperative administration is 2 half-lives after the preoperative dose). Administration of systemic antibacterial drugs (ATC: J01) after wound closure in the operating room is inappropriate even if drains are present.

Single doses of main antibacterial drugs for HAP in surgical interventions in traumatology and orthopedics in adults: cefazolin** 2 g (for patients weighing ≥120 kg – 3 g), cefuroxime** 1.5 g, #clindamycin** 900 mg, vancomycin** 15 mg/kg as a slow IV infusion, ciprofloxacin** 400 mg, #levofloxacin** 500 mg. Single doses for children should be calculated based on actual body weight: cefazolin** 30 mg/kg, cefuroxime** 50 mg/kg, #clindamycin** 10 mg/kg, vancomycin** 15 mg/kg; the use of fluoroquinolones (ATC: J01MA) during the period of musculoskeletal system development is contraindicated due to the risk of arthropathy [132,133]

Comments. In cases of open fractures, systemic prophylactic antibiotic therapy is effective in preventing early infection, and the drug should be administered as soon as possible after the injury. Cefazolin** is the drug of choice; however, in patients with open high-energy fractures with displacement and segmental bone loss; major vascular injury; or heavily contaminated wounds, it is advisable to broaden the spectrum of systemic antibacterial drugs to cover gram-negative pathogens. In such cases, adding #gentamicin** (at a dose of 6 mg/kg once daily) to cefazolin** may be considered [75, 76]. An alternative to this combination is #ampicillin+[sulbactam]** (at a dose of 3.0 g every 8 hours for 3 days) [77], the latter being particularly relevant in the case of a risk of clostridial infection. According to the majority of researchers, in Gustilo and Anderson type III open fractures, antibacterial therapy should not be continued for more than 72 hours after soft tissue wound closure [78].

Thromboprophylaxis

• In cases where general anesthesia or tourniquet time exceeds 90 minutes during upper extremity interventions, as well as if the surgery may significantly impair the patient's mobility or if there is a history of VTE episodes, it is recommended to consider perioperative VTE prophylaxis [81].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: Taking into account the growing population of carriers of genetically determined thrombophilias (antithrombin III, protein C, or S deficiency, factor V Leiden mutation, prothrombin G20210A mutation, etc.), the widespread and often uncontrolled use of estrogens, population aging, and the rising incidence of diabetes and other metabolic disorders that increase the risk of VTE, pharmacological thromboprophylaxis may be advisable in the management of patients with additional VTE risk factors presenting with humeral and forearm fractures, as well as extensive soft tissue injuries of the upper extremities. The final decision is made by the attending physician, taking into account the extent of injury, the nature of the planned intervention, and the patient's additional VTE risk factors. Perioperative administration of LMWHs to this category of patients is possible according to the regimens and dosages given in Appendix 12.3 for a period of 7-10 days (until discharge from the hospital) or for several days until normal/expected mobility is restored.

Recommended medications and thromboprophylaxis regimens are given in Appendix 12.3. Issues regarding VTE prophylaxis in trauma and orthopedic patients are discussed in detail in the 2022 methodological recommendations [30] and the 2023 Russian expert recommendations [35].

Features of thromboprophylaxis in pediatric patients

• Hospitalized patients older than 6 months are recommended to undergo bleeding and VTE risk assessment within 24 hours of admission [83] and periodically during their hospital stay [84–86].

GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3).

Comment. No validated VTE risk assessment scales have been developed for pediatric patients, nor have bleeding risk scales for antithrombotic therapy; therefore, when deciding on VTE prophylaxis, individual bleeding risk factors (Appendix A3.5), VTE risk factors (Appendix A3.6), and the risk-benefit ratio should be taken into account [87, 89].

Mechanical and pharmacological methods are used for VTE prophylaxis in children.

• Pediatric patients at high risk of VTE are recommended to be considered for prophylactic doses of UFH or LMWH [91, 92].

GCP BLeE 3Level of recommendation confidence B (level of evidence reliability – 3).

Comment. LMWHs are preferred for pediatric patients [91, 92], but currently in Russia the use of all LMWHs is contraindicated in children, so their prescription is only possible by decision of a medical commission (off-label use).

Blood-conserving technologies

Comments. Tranexamic acid** effectively reduces blood loss and leads to a smaller decrease in postoperative hemoglobin levels in patients undergoing surgery for proximal humeral fractures. This effect is observed both during fracture osteosynthesis and shoulder arthroplasty.

Comments. Systematic reviews and meta-analyses demonstrate that perioperative use of intravenous iron preparations, in particular ferric carboxymaltose** in trauma and orthopedic patients, especially in the postoperative period, is an effective alternative to blood transfusion, as it reduces the proportion of patients receiving blood transfusions, decreases the volume of red blood cell mass transfused, and reduces the incidence of infectious complications, though it does not alter mortality rates [98, 99].

3.2 Surgical Treatment

- open fractures;

- fractures with signs of compartment syndrome;

- fractures combined with neurovascular disorders and/or tendon injuries;

- bilateral distal forearm bone fractures;

- fracture-dislocations of the wrist joint;

- compression fractures of the articular surface of the radius;

- intra-articular fractures of the distal metaepiphysis of the radius with a fracture line in the coronal plane and dorsal or volar fragment displacement;

- flexion fractures;

- distal radial metaphyseal-epiphyseal fractures as part of polytrauma;

- extension fractures where displacement of fragments persists after reduction: radial shortening of more than 3 mm, dorsal tilt of more than 10 degrees, and articular surface step-off of more than 2 mm [1].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: In nearly a third of cases, distal radial metaphyseal-epiphyseal fractures are associated with a fracture of the distal ulna, predominantly the ulnar styloid process. As a rule, a fracture of the ulnar styloid process does not require surgical fixation. According to observations by foreign authors, nonunion of the styloid process fracture occurs in 55–70% of cases; however, the clinical significance of this complication for the patient's functional outcome remains incompletely defined to this day. In some cases, a fracture of the ulnar styloid process is associated with injury to the distal radioulnar joint and the triangular fibrocartilage complex; therefore, the traumatologist must verify the stability of the distal radioulnar joint following fixation of the distal radial metaphyseal-epiphyseal fracture. In the event of a fracture of the metaphyseal-epiphyseal region of the ulna, its fixation is performed according to the principles of surgical treatment for diaphyseal fractures of the ulna [5].

If there are indications for surgery and the patient refuses inpatient treatment, the reason for refusal must be documented in the medical records with the signature of the patient or their legal guardians (in case of legally established incapacity of the patient).

3.2.1 Percutaneous fixation

Comments: The following implants are used when performing percutaneous osteosynthesis of the forearm bones: Kirschner wire (orthopedic bone wire***).

Percutaneous pinning is the next step when an immobilizing cast fails to maintain fragments in the correct position following closed reduction. In most cases, one or two Kirschner wires are sufficient to fix a simple fracture. If there are multiple fragments, 3 or more wires are used. The wires are inserted through the radial styloid process and/or through the dorsolateral surface of the distal radial metaphyseal-epiphyseal fracture area. Following fixation, control radiography of the wrist joint is performed in 2 projections [4].

3.2.2 Plate Osteosynthesis

- of intra-articular fractures of the distal radius with a fracture line in the frontal plane with dorsal displacement of the fragments or in combination with dorsal wrist dislocation;

- of a fracture with displacement of the lunate fossa articular fragment of the radius [1, 43];

- of comminuted intra-articular fractures of the distal radius using a bridging plate (fixation in the diaphyseal area of the radius and 2nd or 3rd metacarpal bones).

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• In other cases, it is recommended to use a palmar approach for plate osteosynthesis of the distal radius [1, 43].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: When performing plate osteosynthesis of the forearm bones, the following implants are used: non-absorbable sterile bone fracture fixation plate with screws***, non-absorbable non-sterile bone fracture fixation plate with screws***, non-absorbable sterile orthopedic bone screw***, non-absorbable non-sterile orthopedic bone screw***.

At the current stage of traumatology development, surgeons have a wide variety of anatomically pre-contoured plates for distal radius osteosynthesis, including those with angular screw stability. This is due to the variety of distal forearm bone fracture types encountered by traumatologists in surgical practice. The use of low-profile metal implants with carefully selected screw lengths is most preferable to avoid irritation or damage to the extensor and flexor tendons [4, 43]. In all cases of intra-articular distal radius fractures, an effort must be made to achieve anatomic reduction of the articular surface fragments with interfragmentary compression [1]. If necessary, plate osteosynthesis can be supplemented with fragment fixation using Kirschner wires (orthopedic bone wire***) [4].

3.2.3 External Fixation Device

- open fractures with significant soft tissue damage and a high risk of infectious complications from plate osteosynthesis methods;

- extensive skin and soft tissue defects that cannot be eliminated in the early post-traumatic period;

- infection at the surgical site;

- temporary fixation in high-energy trauma;

- distal radius fracture as part of polytrauma;

- as a distraction device during osteosynthesis surgeries;

- as an additional fixation method when instability persists after plate or wire osteosynthesis;

- as an independent osteosynthesis method in comminuted fracture patterns [1].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: When applying an external fixation device for forearm bone fixation, the following implants are used: Schanz pin, Steinmann pin, Kirschner wire (orthopedic bone wire***), wire for osteosynthesis with a stopper (orthopedic bone wire***).

In most cases, the external fixation device is applied with spanning of the wrist joint; however, if the distal radial fragment is sufficiently large to accommodate the transosseous elements of the device, wrist joint immobilization is optional [1].

When placing an external fixator, the topography of major vessels and nerves should be taken into account, and fixation elements (pins and/or wires) should be inserted considering their skin projections [1, 100, 101].

3.2.4 Specific features of surgical treatment in children and adolescents

• In pediatric patients, surgical treatment and metal osteosynthesis are recommended for distal forearm bone fractures when closed reduction fails, in case of tissue interposition, unstable and open fractures, or secondary displacement of fragments after closed reduction. Indications for surgical intervention also include fractures in the distal growth plate regions (Salter-Harris type III–V), neurovascular bundle injury, and Galeazzi fracture [8, 9, 24, 50, 58]. The following are used: fixation of fracture fragments with Kirschner wires (orthopedic bone wire***), plate osteosynthesis in compliance with established principles of stable osteosynthesis [8, 9, 50]. For open injuries, extrafocal osteosynthesis with external fixation devices is performed as a stage of surgical treatment or as the definitive osteosynthesis option [102].

GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).

Comments: when choosing the method of surgical treatment, the child's age, the nature of the injury, and the magnitude of fragment displacement must be taken into account.

3.3 Other Treatment

Comments: In accordance with clauses 4156-4157 of the Sanitary Rules and Norms on the Prevention of Infectious Diseases (SanPiN 3.3686-21), emergency tetanus prophylaxis is carried out for any injuries involving a breach of the skin and mucous membranes. Emergency tetanus prophylaxis is performed up to the 20th calendar day from the moment of injury [103]. The prescription of drugs for emergency tetanus immunoprophylaxis is carried out differentially, depending on the availability of documented proof of preventive vaccination or data from immunological monitoring of anti-tetanus immunity levels, as well as taking into account the nature of the injuries.

Emergency tetanus immunoprophylaxis is carried out in the form of:

- passive immunization or seroprophylaxis with human tetanus immunoglobulin** (HTIG), or in its absence, tetanus antitoxin** (TAT);

- active-passive prophylaxis, consisting of the simultaneous administration into different parts of the body of human anti-tetanus immunoglobulin** (and in its absence - TAT) and tetanus toxoid** (TT);

- emergency revaccination with tetanus toxoid** (or reduced-antigen diphtheria-tetanus toxoid** - Td-toxoid) to stimulate immunity in previously vaccinated individuals [103, 104].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Comments: during the period of immobilization with a plaster cast or rigid orthosis, the objectives of rehabilitation are: reducing pain in the fracture area, swelling of the hand and fingers, and improving blood circulation in the limb. From the first days, active movements in the finger joints, elbow, and shoulder joints, ideomotor movements for the wrist joint, isometric exercises for the forearm muscles, and keeping the forearm elevated are performed. To reduce pain and swelling, local cryotherapy, ultraviolet irradiation (ultraviolet irradiation of the skin, ultraviolet irradiation for joint diseases), and pulsed low-frequency electromagnetic field therapy through the plaster cast are recommended.

Two weeks after the fracture, performing basic household tasks and work activities is possible.

Comments: 4–6 weeks after the fracture, immobilization is removed, and the goal of rehabilitation is the full restoration of hand and finger function, self-care, and upper limb working capacity.

For the first two weeks, the rehabilitation program consists of hydrokinesiotherapy for joint diseases and injuries, dynamic exercises for the hand and fingers, and grasping objects of various shapes, sizes, and weights. Manual and/or hardware massage (barotherapy – limb pressotherapy, pneumatic compression, pulsed low-frequency electrostatic field therapy) helps improve muscle tone and blood circulation in the limb.

Two weeks after the removal of immobilization, during a follow-up appointment (examination, consultation) with a physical and rehabilitation medicine physician / exercise therapy physician, the issue of prescribing dynamic exercises with additional weight and resistance for the prime mover muscles of the elbow and wrist joints is re-evaluated, along with biofeedback training based on dynamographic parameters (strength) and gonioscopic parameters (joint angle) in bone fractures, electrical muscle stimulation (EMS) of muscles correcting contracture in the elbow joint (as indicated), manual therapy for skeletal system disorders to stretch and increase the elasticity of the arm and forearm muscles, and training in household self-care skills (occupational therapy).

Comments: after surgery, the arm is supported in a soft brace. From the first days after surgery, assisted gentle movements in the joints of the operated limb, changing the position in the elbow joint, isometric contraction of the forearm and shoulder muscles, and active movements in the shoulder joint are permitted. Starting from the 2nd–3rd day after the surgical intervention and further as the fracture heals and pain subsides, the range of motion in the joints is gradually increased and activities of daily living are expanded [111].

The objectives of the early postoperative period are the prevention of general postoperative complications. The prevention of local complications includes reducing soft tissue edema and creating optimal anatomical and physiological conditions for the healing of tissues traumatized during surgery. Local cryotherapy, pneumatic compression, low-frequency pulsed electrostatic field therapy, and low-level laser irradiation of the skin are prescribed.

Comments: Following surgery, the wrist is immobilized with a soft brace that allows finger and elbow movements. To reduce edema and pain, local cryotherapy, elevation of the forearm, and portable physical therapy (pulsed low-frequency electromagnetic field therapy, transcutaneous electrical nerve stimulation [TENS]) are used. After 2 weeks, the brace is removed and hydrokinesiotherapy for joint diseases and injuries, low-frequency pulsed electrostatic field therapy, dynamic self-assisted wrist movements, robotic mechanotherapy, mechanotherapy using basic mechanotherapy devices for joint injuries and diseases, and motorized mechanotherapy devices are prescribed; self-care skills and grip function are trained.

As finger and wrist mobility is restored, strength is regained using exercises with weights and resistance, mechanotherapy, and ergotherapy. The question of allowing load on the wrist joint is decided after a follow-up X-ray and a repeat consultation with the PRM/exercise therapy physician no earlier than 4 weeks postoperatively.

5. Prevention and Dispensary Observation

Prevention of distal forearm fractures consists in citizens observing social safety rules when performing household chores, being in traffic zones, walking on poor-quality surfaces, and during icy conditions.

A significant share of responsibility in fracture prevention also belongs to state structures, which are obliged to ensure safety to prevent road traffic injuries, as well as ensure compliance with safety regulations in industries with increased risk of trauma.

Comments. Upon discharge from the hospital, the patient must be referred to a trauma center or outpatient trauma department with an indication of the treatment performed and detailed recommendations for the continuation of treatment and rehabilitation. This ensures continuity between the inpatient and outpatient stages of treatment.

Follow-up examinations with X-ray imaging of the ulna and radius and assessment of functional recovery dynamics are performed at 6–8 weeks postoperatively (assessment of fracture union and the feasibility of full limb loading), 12 weeks postoperatively (assessment of fracture union), 24 weeks postoperatively (assessment of union and functional recovery dynamics), and 1 year postoperatively (assessment of the functional outcome of treatment and determining the need and timing for implant removal).

In cases of low-energy fractures, it is advisable to refer patients to osteoporosis centers (if available) to prescribe therapy aimed at preventing secondary fractures.

In pediatric patients with growth plate injuries accompanied by displacement of bone fragments, following treatment, achievement of union, and completion of a rehabilitation course, follow-up monitoring by an orthopedic traumatologist is recommended to rule out the development of orthopedic complications resulting from the sustained injury as the child grows and develops. An examination and X-ray imaging are recommended 6 months after the injury.

6. Organization of Medical Care

Clinical application of recommendations: Traumatology and Orthopedics, Anesthesiology and Intensive Care, Medical Rehabilitation, Health Organization and Public Health.

Purpose of the clinical guidelines: These clinical guidelines have been developed to improve the quality of medical care and to standardize diagnostic and treatment algorithms for patients with distal forearm fractures.

Indications for elective hospitalization: unsatisfactory result of conservative treatment—secondary fragment displacement, absence of signs of distal forearm fracture union following conservative treatment or osteosynthesis surgery at 2.5–3.5 months post-injury or post-surgery [1, 28, 29].

Indications for emergency hospitalization:

Patients with suspected or confirmed distal forearm fractures must be referred to an inpatient facility if one or more of the following indications for emergency hospitalization are present:

- distal forearm fracture with persistent fragment displacement after closed reduction (radial shortening > 3 mm, dorsal displacement > 10 degrees, articular surface fragment displacement > 2 mm);

- open distal forearm fracture;

- distal forearm fracture with signs of compartment syndrome;

- distal forearm fracture combined with neurovascular disorders and/or tendon injuries;

- fracture-dislocation of the wrist joint;

- compression fracture of the radial articular surface;

- intra-articular distal forearm fracture with a fracture line in the frontal plane and posterior or anterior fragment displacement;

- distal forearm fracture as part of polytrauma;

- bilateral distal forearm fracture [1, 4, 43].

Indications for emergency hospitalization for a distal forearm fracture are established based on the presence of:

1) symptoms characteristic of a distal forearm fracture;

2) clinical signs characteristic of a distal forearm fracture;

3) radiological signs of a distal forearm fracture.

Indications for patient discharge from the hospital:

1. Internal fixation of the fracture with hardware, stabilization with an external fixation device, or adequate plaster immobilization in conservative treatment has been performed.

2. The first stage of rehabilitation has been completed.

3. There is no acute infectious process.

4. Refusal of the patient or their legal guardians in case of legally established incapacity of the patient to continue inpatient treatment (the reason for refusal must be recorded in the medical chart with the personal signature of the patient or their guardians).

5. A pediatric patient may be discharged after achieving fragment reduction confirmed radiographically, provided that the residual displacement does not exceed the acceptable limit for the age category and complications are absent or resolved. Furthermore, follow-up radiographs taken after tissue swelling subsides must show no secondary fragment displacement, and in the case of surgical treatment, the hardware position must be correct with no signs of infectious and inflammatory complications.

7. Additional Information

No additional information is required.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Belenky I.G., MD, DSc, Associate Professor, Saint Petersburg I.I. Janelidze Research Institute of Emergency Medicine, Saint Petersburg, member of ATOR

2. Bozhkova S.A., Doctor of Medical Sciences, Vreden National Medical Research Center of Traumatology and Orthopedics of the Russian Ministry of Health, St. Petersburg, member of ATOR

3. Geroeva I.B., MD, DSc, Professor, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Moscow.

4. Zhuravlev S. A., traumatologist-orthopedist, Privorotov National Medical Research Center of Traumatology and Orthopedics of the Russian Ministry of Health, Moscow, member of ATOR

5. Zorin V.I., PhD, Associate Professor, Turner National Medical Research Center for Children's Orthopedics and Trauma of the Ministry of Health of Russia, St. Petersburg.

6. Kleimenova E.B., MD, DSc, Professor, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Moscow.

7. Mayorov B.A., Ph.D. in Medicine, Janelidze St. Petersburg Research Institute of Emergency Medicine, Pavlov First St. Petersburg State Medical University, St. Petersburg, member of ATOR

8. Mamedov N. A., traumatologist-orthopedist, Privorotov National Medical Research Center of Traumatology and Orthopedics of the Russian Ministry of Health, Moscow, member of ATOR.

9. Nazarenko A.G., MD, DSc, Professor of the RAS, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Moscow, Vice President of ATOR.

10. Otdelenov V.A., PhD, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Moscow.

11. Semenov S.Yu., traumatologist-orthopedist, Turner National Medical Research Center for Children's Orthopedics and Trauma of the Russian Ministry of Health, Saint Petersburg.

12. Sergeev G.D., PhD, Saint Petersburg Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, member of ATOR

Conflict of interest.

The working group responsible for drafting these clinical guidelines has no conflicts of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Trauma and orthopedic surgeons

2. Surgeons

3. General practitioners (family physicians)

4. Medical rehabilitation physicians

5. Healthcare organization and public health specialists.

Stages of evaluating the levels of evidence and grades of recommendation:

1. Definition of search and selection criteria for publications on clinical trials (CT) regarding the efficacy and/or safety of the medical intervention described in the recommendation statement.

2. Systematic search and selection of CT publications in accordance with the previously defined criteria.

Systematic search and selection of clinical trial publications:

The evidence base for the recommendations consisted of publications retrieved via information retrieval in the following databases: Central Scientific Medical Library (CSML) "Russian Medicine", MEDLINE (US NLM), and COCHRANE Library; scientific electronic libraries eLibrary.ru and "CyberLeninka"; as well as on the Internet using Yandex, Google, and Google Scholar search engines, by reviewing leading specialized peer-reviewed domestic medical journals on the subject and treatment guidelines for fractures from the international Association for Osteosynthesis AO/ASIF.

Table 1. Scale for assessing levels of reliable evidence (LRE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The update mechanism for clinical guidelines provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific conditions, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Appendix A3.1. Guidelines for pain management in major musculoskeletal trauma (surgical interventions for long bone fracture fixation or complex articular fracture, extensive soft tissue trauma, major surgery, etc.) in adults

Appendix A3.2. Guidelines for pain management in musculoskeletal trauma without surgery (closed fractures, superficial wounds, etc.) in adults

The table presents analgesic drugs and their dosage regimens in accordance with the Clinical Guidelines for Pain Management in Acute Musculoskeletal Trauma [69].

Appendix A3.3. Dosing regimen of analgesics for children

¹ In children under 12 years of age, morphine** is preferred when opioid analgesics are indicated, as the use of tramadol** is associated with a higher risk of adverse reactions [143,144].

² Not recommended for use in children, because its metabolite accumulates in the body and provokes seizures upon repeated administration [145].

Appendix A3.4. Recommended dosage regimen of low-molecular-weight heparins for the prevention of high-risk VTE in conservative treatment and orthopedic surgery in adult patients at high risk of VTE

It should be noted that spinal or epidural anesthesia can be performed only 12 hours after the administration of a low-molecular-weight heparin dose and no earlier than 4–6 hours after the administration of unfractionated heparin (while aPTT or ACT values must be within the normal range) [134,135].

Appendix A3.5 Bleeding risk factors in children aged 6 months to 18 years

Notes:

1. If the patient meets at least one "NOT recommended" criterion, avoid pharmacoprophylaxis, as the risk outweighs the benefit.

2. If the patient has at least one relative contraindication criterion, consider withholding pharmacoprophylaxis.

3. Consider consulting a hematologist if the patient is at high VTE risk with a high bleeding risk [85].

4. Uncontrolled hypertension is defined as systolic or diastolic blood pressure above the 95th percentile for age, height, and sex [86].

5. Coagulopathy is defined as INR >1.5, aPTT >44 s, fibrinogen <100 mg/dL, or platelets <50,000/μL.

Appendix A3.6 VTE risk factors in children aged 6 months to 18 years

Notes:

− Reduced mobility is defined as a decrease in mobility compared to baseline or the inability to participate in physical therapy.

− A central venous access device is defined as a non-tunneled catheter, tunneled catheter, or central venous catheter.

− A major burn is defined as a burn involving more than 50% of the body surface area.

− Major surgical procedures include operations lasting longer than 45 minutes.

− Critically ill patients are defined as those admitted to an intensive care unit (requiring inotropic support or mechanical ventilation).

− Thrombophilic states include antithrombin deficiency, protein C or S deficiency, factor V Leiden, or prothrombin gene mutation.

− Active malignancy is defined as receiving chemotherapy/radiation therapy within the preceding 6 months.

− Active inflammatory disease includes Kawasaki disease, inflammatory bowel disease, systemic lupus erythematosus, or nephrotic syndrome.

− Estrogen therapy includes oral contraceptives, estrogen replacement therapy, or use within the past 2 weeks.

− Obesity is defined as a BMI above the 95th percentile for age.

Key:

Low VTE risk:

• No altered mobility and 0-1 risk factors

Moderate VTE risk:

• No mobility impairment and 2-3 risk factors

• Altered mobility and 0-1 other risk factors

High VTE risk:

• No mobility impairment and ≥4 risk factors

• Altered mobility and ≥2 other risk factors

Thromboprophylaxis recommendation

Appendix B. Physician Action Algorithms

Appendix B1. Physician's Algorithm for the Management of Distal Forearm Fractures

Appendix B2. Algorithm for assessing cardiovascular risk of surgery

Notes and abbreviations:

CVRF – cardiovascular risk factors (hypertension, smoking, dyslipidemia (elevated total cholesterol >4.9 mmol/L and/or LDL cholesterol >3 mmol/L and/or HDL cholesterol <1.0 mmol/L in men, <1.2 mmol/L in women, and/or triglycerides >1.7 mmol/L), diabetes mellitus, family history of premature cardiovascular disease (<55 years for men and <65 years for women);

CVD – cardiovascular disease (coronary artery disease, cerebrovascular disease, peripheral artery disease, chronic heart failure, pulmonary hypertension, valvular heart disease, cardiomyopathies);

rRCRI – reconstructed RCRI index (See Appendix G.2);

FS – functional status (the patient's ability to climb 2 flights of stairs independently without stopping before the injury).

* – regional vascular center or specialized cardiology department.

Appendix C. Patient Information

Distal forearm fractures are injuries requiring specialized treatment in a trauma center or traumatology department. Conservative treatment of such injuries is possible for fractures without fragment displacement, as well as for fractures with fragment displacement in the absence of indications for surgical treatment. Conservative treatment involves immobilization with a plaster cast or its analogs for 5–7 weeks until fracture union. The main disadvantage of upper extremity immobilization is a decrease in quality of life and prolonged rehabilitation due to the development of wrist and, occasionally, elbow contractures. Surgical treatment is indicated for fractures with unacceptable fragment displacement, which may subsequently affect the functional outcome of treatment. Special plates with 3.5 mm screws, Kirschner wires, and external fixation devices in various configurations can be used to treat distal radius fractures. Treatment can be single-stage (for isolated closed fractures and satisfactory soft tissue condition) and two-stage, where the fracture is temporarily fixed with an external fixator followed by conversion to internal fixation (in multiple and polytrauma cases, severe open fractures, and significant soft tissue injury). In intra-articular fractures of the distal radius, one should strive for complete restoration of the damaged articular surface of the bone. In extra-articular trauma, it is necessary to restore the axis, segment length, and eliminate rotational displacement. To this end, it is usually necessary to open the fracture site and reduce the fragments under direct vision. In all cases, one should strive to achieve stable osteosynthesis that does not require additional external immobilization after surgery. This makes it possible to start early rehabilitation treatment.

Rehabilitation treatment should begin immediately after surgery. It consists of passive and active movements in the joints of the upper extremity, physiotherapeutic procedures, and exercises aimed at normalizing the trophic supply of the damaged soft tissues and bone.

In cases of fracture-dislocations, active movements in the elbow and wrist joints may be restricted for up to 3 weeks after surgery, depending on the clinical situation.

During conservative treatment in the immobilization period, it is necessary to perform active movements in the hand, elbow, and shoulder joints. Active movements in the wrist joint should be initiated immediately after the removal of immobilization if there are radiological signs of fracture union.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

QuickDASH upper extremity disability questionnaire

Russian title: The shortened disabilities of the arm, shoulder and hand questionnaire.

Original title: The shortened disabilities of the arm, shoulder and hand questionnaire (Quick DASH)

Source: Quick DASH Outcome Measures: Russian translation. Institute for Work & Health, 2006. https: //dash.iwh.on.ca /available-translations

Type: questionnaire

Purpose: assessment of the impact of musculoskeletal injuries and diseases on upper extremity function.

Content:

INSTRUCTIONS: This questionnaire asks about your symptoms as well as your ability to perform certain activities. Please answer each question based on your condition over the past week by circling the appropriate number. If you did not have the opportunity to perform a specific activity last week, please choose the most appropriate response. It does not matter which hand you use to perform the action; please answer based on your ability, regardless of how you independently perform the task.

OPTIONAL MODULE SCALING. All 4 questions must be answered. Simply add the assigned values for each response and divide by 4 (number of items); subtract 1 and multiply by 25.

Notes and Comments:

To assess treatment outcomes in patients with fractures at the shoulder girdle and arm level, questionnaires have been developed to evaluate the functional result of treatment.

1) Disabilities of the Arm, Shoulder, and Hand questionnaire (Disabilities of the Arm, Shoulder, and Hand, English – DASH) – developed jointly by the American Academy of Orthopaedic Surgeons (American Academy of Orthopaedic Surgeons), the Council of Musculoskeletal Specialty Societies (Council of Musculoskeletal Specialty Societies), and the Institute for Work and Health of Canada (Institute for Work and Health). It belongs to patient-reported outcome measures (patient-reported outcome measures) and was introduced in 1996 for the standardized assessment of the impact of various musculoskeletal injuries and diseases on upper extremity function [115]. DASH is a 30-item questionnaire with response options presented as a 5-point Likert scale. Scores range from 0 (no functional limitations) to 100 (most severe functional limitations). The questionnaire is intended for patients with any musculoskeletal disorders of the upper extremities [116]. DASH has two optional modules (four items each) intended for athletes, musicians, and workers whose activities require special physical fitness and whose functional limitations may occur only at high loads exceeding the scope of the 30 DASH items. Approved translation versions of DASH in 56 languages and dialects, including Russian, are available on the website of the Institute for Work and Health of Canada, which owns the copyright to the questionnaire (https://dash.iwh.on.ca/available-translations).

2) Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) is a shortened 11-question version of the DASH questionnaire with the same response options [117, 118]. Like DASH, it is designed for patient self-assessment of the degree of upper extremity functional impairment in various diseases and injuries. QuickDASH also has two optional modules (four items each) intended for athletes, musicians, and workers whose activities require special physical fitness and whose functional limitations may occur only at high loads exceeding the scope of the 11 QuickDASH items. The optional modules are scored separately. In a number of studies, comparison of the DASH and QuickDASH questionnaires showed that both instruments have approximately equal sensitivity, specificity [119–123], and minimal clinically important difference values (12–14 points for DASH and 12–15 points for QuickDASH) [124]. In a systematic review of 23 self-assessment instruments for patients with various upper extremity pathologies, the QuickDASH questionnaire showed the highest content and construct validity, reliability, and responsiveness [125]. There are reports of the successful use of QuickDASH in children aged 8–18 years [126, 127]. Approved translation versions of QuickDASH in 56 languages and dialects, including Russian, are available on the website of the Institute for Work and Health of Canada, which holds the copyright (https://dash.iwh.on.ca/available-translations).

Appendix G2. Caprini Risk Assessment Model for Venous Thromboembolism

Russian title: Caprini risk assessment model for venous thromboembolism.

Original title: Caprini Score for Venous Thromboembolism

Source: Lobastov K.V., Barinov V.E., Schastlivtsev I.V., Laberko L.A. Caprini score as a tool for individual risk stratification of postoperative venous thromboembolism in high-risk group. Pirogov Russian Journal of Surgery. 2014; (12):16-23.

Type: scale

Purpose: assessment of venous thromboembolism risk

Content:

1 point

Age 41-60 years

Lower extremity edema

Varicose veins

Body mass index > 25 kg/m²

Minor surgery

Sepsis (< 1 month)

Severe pulmonary disease (including pneumonia < 1 month)

Oral contraceptive use, hormone replacement therapy

Pregnancy and postpartum period (< 1 month)

History of unexplained stillbirths, spontaneous abortions (≥3),

Premature birth with preeclampsia or intrauterine growth restriction

Acute myocardial infarction

Chronic heart failure (< 1 month)

Bed rest in a non-surgical patient

History of inflammatory bowel disease

History of major surgery (< 1 month)

Chronic obstructive pulmonary disease

2 points

Age 61-74 years

Arthroscopic surgery

Malignant neoplasm

Laparoscopic surgery (duration > 45 min)

Bed rest > 72 h

Limb immobilization (< 1 month)

Central venous catheterization

Major surgery (duration > 45 min)

3 points

Age > 75 years

Personal history of VTE

Family history of VTE

Factor V Leiden mutation

Prothrombin G20210A mutation

Hyperhomocysteinemia

Heparin-induced thrombocytopenia

Elevated anticardiolipin antibodies

Lupus anticoagulant

5 points

Stroke (< 1 month)

Multiple trauma (< 1 month)

Major joint arthroplasty

Femur and lower leg fractures (< 1 month)

Spinal cord injury/paralysis (< 1 month)

Key: Depending on the score obtained from history taking and patient examination, the patient is assigned to a specific risk group:

low risk: 0-1 point;

moderate risk: 2 points;

high risk: 3-4 points;

very high risk: 5 points or more.

Appendix G3 Revised Cardiac Risk Index (rRCRI)

Russian title: Reconstructed Revised Cardiac Risk Index for noncardiac surgical procedures

Original title: Reconstructed Revised Cardiac Risk Index (rRCRI)

Source: Davis C., Tait G., Carroll J. et al. The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients. Can. J. Anaesth. 2013; 60(9): 855-863.

Type: scale

Purpose: prediction of the risk of perioperative cardiac complications in noncardiac surgery: myocardial infarction, pulmonary edema, ventricular fibrillation or cardiac arrest, complete AV block.

Content:

1. High-risk surgery (thoracic, major abdominal, or vascular surgery above the groin) – 1 point.

2. Coronary artery disease (myocardial infarction, positive stress test, angina, nitroglycerin use, pathological Q wave on ECG) – 1 point.

3. Heart failure (history of heart failure, pulmonary edema, paroxysmal nocturnal dyspnea, bilateral rales, gallop rhythm, pulmonary congestion on chest X-ray) – 1 point.

4. TIA/Stroke – 1 point.

5. Creatinine clearance <30 ml/min – 1 point

Scoring:

• total score of 0 – low risk of cardiovascular complications;

• a total score of 1 – moderate risk of cardiovascular complications;

• a total score of 2 or more – high risk of cardiovascular complications.

Notes:

The RCRI index was developed in 1977 [129] to predict the risk of perioperative cardiac complications in non-cardiac surgery. It was validated in the Lee study [130], and in 2013 [131] it was revised and re-validated based on clinical risk factors (instead of the criterion "creatinine level >176.8 µmol/L", the scale uses the criterion "creatinine clearance <30 ml/min"; the clinical criterion "insulin-dependent diabetes mellitus" was removed), which is why it is called the reconstructed index. It includes 5 parameters, each assigned 1 point. This particular version of the index is recommended by the Russian Society of Cardiology [35].