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Currently, there is little information regarding risk factors for failure of nonoperative treatment in Salter-Harris II distal radius fractures (SHII-DRF). Our purpose is to identify predictors of which patients will require acute surgery and which will develop late malunion based on degree of deformity and skeletal maturity.


This was a review of SHII distal radius fractures from 2017-2020. Patients between 9 and 18 years of age were included. Outcomes of interest included measurements of initial displacement, displacement post-reduction, and displacement after cast removal. These values were compared between patients who did not undergo surgery, had acute surgery, or had late malunion correction. A Classification and Regression Tree (CART) model was also created to identify predictors of acute surgical intervention.


271 (70% male) SHII distal radius fractures were identified, of which 34 cases (13%) underwent surgical intervention with CRPP or ORIF. Twenty-two (65%) surgical cases were early (median 9.5 days, IQR 3.2-14 days) and 12 (35%) cases were performed to correct late malunion (median 459.5 days, IQR 325.5-542 days). No patients who underwent acute surgery developed malunion. A significantly greater proportion of patients in the late malunion group had dorsal angulation post-reduction compared to the nonoperative group (58% vs. 29%, p=0.048). Similarly, the magnitude of post-reduction tilt was significantly greater in the late malunion group compared to the nonoperative group (median 9, IQR 5-12 vs. median 3, IQR 0-11, p=0.042). Late malunion patients were also significantly older than patients who had successful nonoperative treatment (median 13.7 years vs. median 12.2 years, p=0.038). This information can be found in Table 1. The CART model correctly classified 94% of acute surgery patients with a sensitivity of 55% and specificity of 97%. The CART classification tree and predictors of early surgical intervention can be found in figure 1.


In SHII distal radius fractures, persistent dorsal angulation after casting was associated with late malunion. Increased Sander’s class and magnitude of deformity in all planes following closed reduction and casting were associated with acute surgery. Treatment guidelines for surgical intervention of this fracture type based on skeletal maturity are limited and this study is among the first to describe treatment that considers skeletal age. These cutoff values for degree of deformity and skeletal maturity can be used to predict need for acute surgery.

Document Type


Indications for Early Surgical Intervention in Adolescents with Salter-Harris II Distal Radius Fractures