Variation in surgical indications across national distal radius fracture guidelines: A comparative review.

Abstract

Surgical indications for dorsally displaced distal radius fractures (DRFs) are guided by national guidelines, yet variation in clinical practice persists. This study aimed to compare contemporary national guidelines, examine differences in recommended intervention thresholds, and assess their potential impact on treatment decisions and resource utilization. A structured search was conducted across biomedical databases, clinical knowledge platforms, guideline repositories, and national health agency websites. National guidelines were included if they provided surgical recommendations for dorsally displaced DRFs in adults. Radiographic thresholds, patient-related criteria, and methodological characteristics were extracted and analysed comparatively. Eight national guidelines were included in the comparative analysis (one from the United States and seven from Europe). Ulnar variance, dorsal tilt, and intra-articular step-off were consistently identified as key radiographic indicators for surgery, although threshold values and age-related modifications varied. Additional parameters, including volar cortical alignment, fracture comminution, osteoporosis, and intra-articular gap, were incorporated inconsistently. Some guidelines applied fixed age thresholds, whereas others emphasised functional demand. Despite methodological variation, recommendations were derived from a largely shared but methodologically limited evidence base, with expert consensus playing a substantial role. These differences may have implications for surgical rates and healthcare resource use across healthcare systems. Variation across national DRF guidelines reflects both limitations in the evidence base and differences in clinical prioritisation. The findings highlight ongoing uncertainty in the evidence base and support the need for clearer definitions of instability and stronger links between radiographic parameters and clinically relevant outcomes. International consensus initiatives are needed to support more consistent surgical indications and improve healthcare efficiency.