Loss of Reduction Following Nonoperative Management for Distal Radius Fractures

Background: Loss of reduction during nonoperative management of distal radius fractures can lead to delayed operative treatment, malunion, and corrective osteotomy. This study aimed to systematically review and synthesize the available literature on predictors of loss of reduction of distal radius fractures for adult patients undergoing nonoperative treatment. Methods: MEDLINE, Embase, CINAHL, and Cochrane databases were searched from inception to June 9, 2025. Screening, data extraction, risk of bias assessment, and evidence grading were completed in duplicate. Data were pooled using random-effects models with inverse of variance weights to produce summary of effect odds ratios (ORs) with 95% confidence intervals (CIs). Bivariable prognostic factors and coefficients from multivariable models were pooled separately. Certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation framework. Results: A total of 7,926 citations were screened, and 30 studies (7,495 fractures) met inclusion criteria. In bivariable analyses, 5 predictors demonstrated moderate certainty associations with loss of reduction: dorsal comminution (OR 2.69, 95% CI 1.67-4.32), failure to re-establish volar cortical alignment (OR 3.22, 95% CI 1.93-5.37), prereduction dorsal angulation >20° (OR 1.90, 95% CI 1.04-3.48), displacement beyond acceptable criteria vs minimally displaced fractures (OR 6.15, 95% CI 3.35-11.31), and age older than 60 years (OR 2.24, 95% CI 1.06-4.74, moderate certainty). In multivariable analyses, age older than 60 years (adjusted OR 3.80, 95% CI 1.59-9.10) and prereduction ulnar positive variance (adjusted OR 1.49 per 1-mm increase, 95% CI 1.09-2.06) demonstrated high certainty associations with loss of reduction. The weighted proportion of patients who lost reduction was 43.4% (95% CI 38.7-48.2). Conclusion: Age older than 60 years and increasing prereduction ulnar positive variance demonstrated high certainty associations with loss of distal radius reduction from available multivariable analyses. Further well-designed prognosis studies are needed to better delineate the predictors of loss of reduction with nonoperative management of distal radius fractures. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.