Roughly two out of three patients who undergo surgery for a distal radius fracture experience at least one complication of some kind, though the vast majority are minor and resolve without further surgery. That headline number, drawn from a secondary analysis of a randomized trial, sounds alarming until you see how broadly “complication” is defined: it includes temporary nerve tingling, mild stiffness, and pin-site irritation alongside the rarer problems that actually require reoperation. The gap between “any complication” and “a complication that changes your life” is enormous, and understanding what falls where is the first step toward realistic expectations after wrist surgery.
How Common Are Complications, Really
The answer depends entirely on what you count. In the WRIST trial, a large multicenter study of adults over 60, about 65% of surgically treated patients reported at least one complication across all fixation methods. Nerve and bone-related issues were the most common categories, while tendon problems were less frequent. In the group treated with casting alone, malunion (the bone healing in an imperfect position) topped the list at about 34%, followed by arthritis at 25%.1JAMA Network Open. Assessment of Distal Radius Fracture Complications Among Adults 60 Years or Older: A Secondary Analysis of the WRIST Randomized Clinical Trial Those numbers reflect an older population with more fragile bones, so they skew high compared to what a younger patient might face.
When researchers narrow the definition to complications that actually require a second procedure, the picture changes dramatically. A large retrospective study of nearly 1,600 wrists treated with a single type of volar locking plate found a total complication rate of about 7.5%, split roughly evenly between major and minor complications.2Journal of Hand Surgery. The Rate of Major Complications Following Distal Radial Fractures Treated With One Specific Volar Locking Plate: A Retrospective Study of 1,597 Consecutive Cases in 1,564 Patients That gap between 65% and 7.5% tells you how much the definition matters. Both numbers are honest; they are just measuring different things.
Reoperation rates also vary by the type of hardware used. A population-level study found that patients treated with plates had a higher reoperation rate per person-year than those treated with external fixation or pins, though the timing differed: pinning and external fixation patients tended to develop complications earlier, while plated patients had issues that surfaced later.3Journal of Orthopaedic Trauma. Complications After Distal Radius Fracture Surgery This likely reflects the nature of plate-related problems, which involve slow wear on tendons and delayed hardware irritation rather than the immediate wound issues that come with pins sticking through the skin.
Tendon Damage From the Inside
Tendon problems are among the most talked-about complications of volar plating because they can appear months or even years after surgery, long after you have stopped thinking about the operation. The tendon most at risk is the flexor pollicis longus (FPL), the tendon that bends your thumb. It runs directly over the surface of a volar plate, and if the plate sits even slightly too far toward the fingertips, repetitive contact can gradually fray and eventually rupture the tendon. Plates positioned at or past the watershed line of the distal radius have a higher rate of this attritional wear.4PubMed. Effects of Volar Tilt, Wrist Extension, and Plate Position on Contact Between Flexor Pollicis Longus Tendon and Volar Plate
FPL rupture is considered rare in absolute terms, but when it happens, the consequences are significant: you lose the ability to bend the tip of your thumb, which affects pinch grip and fine motor tasks. In one cohort study, all ruptures occurred in patients whose plates were graded as only mildly prominent, and some happened up to three years after surgery.5PubMed Central. Outcomes of Flexor Pollicis Longus Reconstruction for Volar Plate Related Ruptures A case report documented one rupture at 40 months, even though the plate edge was positioned at the accepted anatomical landmark.6PubMed Central. Delayed rupture of flexor pollicis longus after volar plating for a distal radius fracture The takeaway is that even a well-placed plate can cause trouble over time, especially if the fracture settles and changes the relationship between the plate edge and the tendon.
Extensor tendons on the back of the wrist face a different threat. They sit on the opposite side of the bone from where a volar plate is placed, so direct plate contact is not the issue. Instead, the risk comes from screws that are slightly too long and poke through the dorsal cortex. A systematic review identified dorsal screw prominence and fracture fragments as the main culprits behind extensor tendon injuries after volar plating.7PubMed Central. Extensor Tendon Injury After Volar Locking Plating for Distal Radius Fractures: A Systematic Review A separate study found that screw protrusion greater than about 1.6 millimeters on the dorsal side was significantly associated with tendinitis, and the second extensor compartment (the one housing the wrist extensors) was the most commonly affected.8PubMed Central. Is tendinitis in volar plating related to the dorsally protruding screw length and its compartment?
Nerve Compression and Carpal Tunnel Syndrome
Median nerve compression was one of the most frequently recorded complications across all treatment groups in the WRIST trial, affecting roughly 15% to 25% of patients depending on the fixation method, with casting and pinning at the higher end.1JAMA Network Open. Assessment of Distal Radius Fracture Complications Among Adults 60 Years or Older: A Secondary Analysis of the WRIST Randomized Clinical Trial Carpal tunnel syndrome after a distal radius fracture is not a single entity. It shows up in distinct waves with different causes.
A retrospective study of 105 wrists classified post-fracture carpal tunnel into three onset patterns. Acute cases, appearing within the first week, were strongly linked to high-energy injuries and complex fracture patterns. Subacute cases, showing up between one and twelve weeks, and delayed cases, emerging after three months, were more common in older women with simpler fracture types. In the delayed group, about 70% of patients already had signs of median nerve dysfunction in the opposite wrist, suggesting that the fracture unmasked a preexisting tendency toward carpal tunnel rather than directly causing it.9Journal of Orthopaedic Science. Differential onset patterns and causes of carpal tunnel syndrome after distal radius fracture: a retrospective study of 105 wrists
Whether surgeons should routinely release the carpal tunnel at the time of fracture fixation remains debated. A review on the topic noted that patients who fracture their distal radius are at elevated risk for carpal tunnel syndrome both acutely and in the weeks or months afterward, but the evidence has not settled whether prophylactic release improves outcomes compared to treating symptoms if and when they develop.10Journal of Hand Surgery Global Online. Prophylactic Carpal Tunnel Release During Volar Plating of Distal Radius Fractures: A Review
Interestingly, a meta-analysis comparing volar versus dorsal plate fixation found that the volar approach was associated with a higher risk of nerve-related complications overall and a roughly fourfold increase in carpal tunnel syndrome specifically, while the dorsal approach carried more tendon irritation.11PubMed. Complications following dorsal versus volar plate fixation of distal radius fracture: a meta-analysis Despite this, volar plating has become the dominant technique worldwide because it avoids the extensor tendon issues that plagued dorsal plates in earlier decades, and the total complication rates between the two approaches are statistically similar.12PubMed Central. Dorsal or Volar Plate Fixation of the Distal Radius: Does the Complication Rate Help Us to Choose?
Infection Rates Depend Heavily on What Is Sticking Through the Skin
The single biggest predictor of infection after distal radius surgery is whether the hardware stays entirely under the skin or pokes through it. A nationwide cohort study of more than 31,000 patients found surgical site infection rates of about 5% with plate fixation, 12% with percutaneous pinning, and 28% with external fixation. After adjusting for patient factors, external fixation carried nearly seven times the infection risk of plating, and percutaneous pinning carried about 2.7 times the risk.13PubMed Central. Surgical site infections after distal radius fracture surgery: a nation-wide cohort study of 31,807 adult patients
A systematic review confirmed the pattern, finding pin-tract infections accounted for about 61% of all reported infections, with the overall infection rate across fixation methods sitting around 5%. Plate fixation had the lowest infection rate at roughly 2%, while Kirschner-wire fixation came in around 12% and external fixation around 14%.14PubMed Central. Epidemiology and treatment of surgical infections after distal radius fractures: a systematic review The good news is that deep infection after plate fixation is genuinely uncommon, reported at less than 1%, and when it does occur it typically responds to hardware removal and antibiotics.15PubMed Central. Deep Infection after Distal Radius Open-reduction Internal Fixation: A Case Series
When the Plate Needs to Come Out
Not every complication after volar plating requires plate removal, and not every plate removal is driven by a complication. A systematic review found an average hardware removal rate of about 9%, with the reasons roughly split among routine removal (22%), tendon irritation or tenosynovitis (14%), hardware problems (14%), and patient request (13%). There was a strong correlation between removal rate and complication rate, suggesting that practices with higher complication awareness tend to remove hardware more proactively.16PubMed. A systematic review of volar locking plate removal after distal radius fracture
At one institution, among 33 patients who had their plates removed, pain was the most common reason at 30%, followed by tenosynovitis (27%), malunion (24%), and infection (12%).17PubMed. Incidence and reasons for hardware removal following operative fixation of distal radius fractures On the flip side, a study comparing patients who kept their dorsal plates versus those who had them removed found that the removal group had worse subjective scores, suggesting the plates were removed because patients were already doing poorly, not that keeping a plate in caused problems for those without symptoms.18PubMed. Is an implant removal after dorsal plating of distal radius fracture always needed? The practical point: if your plate is not causing pain, tendon symptoms, or stiffness, there is usually no medical reason to take it out.
Complex Regional Pain Syndrome
Complex regional pain syndrome (CRPS) is the complication patients fear most and understand least. It involves exaggerated pain, swelling, color changes, and stiffness in the affected limb that are out of proportion to the original injury. A case report described a patient who developed CRPS three months after a distal radius fracture, with the forearm showing swelling, warmth, pain, and severely limited movement.19PubMed Central. Complex Regional Pain Syndrome after Distal Radius Fracture-Case Report and Mini Literature Review It can occur after both surgical and nonsurgical treatment, and the mechanism is still not fully understood.
Vitamin C supplementation has been explored as a preventive measure, though the evidence is mixed. One large multicenter trial found that 500 milligrams of vitamin C daily for 50 days after a wrist fracture reduced CRPS rates from about 10% in the placebo group to under 2%.20PubMed. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study However, a meta-analysis pooling three trials concluded that vitamin C did not reach a statistically significant benefit for CRPS prevention, noting substantial inconsistency across studies.21Journal of Orthopaedic Trauma. Vitamin C to Prevent Complex Regional Pain Syndrome in Patients With Distal Radius Fractures: A Meta-Analysis of Randomized Controlled Trials A smaller trial testing regional vitamin C delivery (injected into the arm via a tourniquet-controlled technique) found a much larger apparent effect, with CRPS rates of about 23% in the vitamin C group versus 46% in controls.22PubMed. Regional vitamin C in Bier block reduces the incidence of CRPS-1 following distal radius fracture surgery Given the low cost and safety of oral vitamin C, many surgeons still recommend it despite the uncertain meta-analytic findings, but it is far from a guaranteed shield.
Joint Stiffness and What Drives It
Some degree of wrist stiffness after surgery is nearly universal in the short term, but persistent stiffness that limits daily function is a distinct problem. A study that tracked risk factors for radiocarpal joint stiffness after surgical fixation found four independent predictors: having a fracture that extended into the joint surface, severe swelling before surgery, inadequate restoration of the normal tilt of the bone on the palm side, and improper rehabilitation exercise.23PubMed Central. Radiocarpal joint stiffness following surgical treatment for distal radius fractures: the incidence and associated factors Of those four, rehabilitation was the only one patients could influence after surgery. Starting exercises too aggressively risks swelling and pain, but waiting too long allows scar tissue to stiffen the joint. The timing and intensity of hand therapy matter more than most patients realize.
Longer-term joint degeneration is a concern when a fracture involves the wrist joint surface. Displaced intra-articular fractures that are not perfectly reduced leave a step-off in the cartilage surface, and even small mismatches can alter how forces are distributed across the joint. Post-traumatic osteoarthritis of the wrist is a recognized outcome of this altered mechanics, though the exact threshold of step-off that reliably leads to arthritis is not well defined.24PubMed Central. A three-dimensional finite element model of the radiocarpal joint: distal radius fracture step-off and stress transfer
Instability at the Other Wrist Joint
The distal radioulnar joint (DRUJ), where the radius and ulna meet near the wrist, is frequently injured alongside distal radius fractures but often overlooked during initial treatment. When the triangular fibrocartilage complex (TFCC), the soft tissue structure that stabilizes this joint, is torn, the forearm’s ability to rotate palm-up and palm-down can be affected. A meta-analysis comparing management strategies for acute DRUJ instability after distal radius fracture found that surgical TFCC repair actually led to lower grip strength and less forearm rotation compared to simpler treatments like casting or wire stabilization.25PubMed Central. Management of Acute Distal Radioulnar Joint Instability Following a Distal Radius Fracture: A Systematic Review and Meta-Analysis That counterintuitive finding suggests that in the acute setting, less invasive stabilization may be enough, and aggressive soft tissue repair might impair the very mobility it is trying to protect.
Catching Screw Problems Before They Cause Trouble
Screws that inadvertently penetrate the joint surface or protrude through the back of the bone are a preventable source of complications, but detecting them during surgery is harder than it sounds. Standard X-ray views taken in the operating room miss a surprising number of problem screws. In a cadaver study, rotational fluoroscopy (a moving X-ray sweep) achieved 93% sensitivity and 96% specificity for detecting screws that had broken through into the joint, significantly outperforming most standard static views.26PubMed Central. Rotational fluoroscopy assists in detection of intra-articular screw penetration during volar plating of the distal radius
For dorsal screw penetration, specialized angled views are needed. A study comparing four fluoroscopic views found that the dorsal tangential view was 95% sensitive for detecting even one millimeter of screw penetration into the third dorsal compartment, while the standard lateral view caught only 68% of the same penetrations.27PubMed. Comparison of 4 fluoroscopic views for dorsal cortex screw penetration after volar plating of the distal radius These imaging techniques are part of what separates a thorough intraoperative check from a cursory one, and they directly reduce the risk of tendon irritation and joint damage down the road.
Who Is at Higher Risk
Smoking is one of the clearest modifiable risk factors. A study of 417 patients at a level-one trauma center found that smokers had significantly higher complication rates after distal radius fixation, and this held even after accounting for diabetes and obesity.28PubMed Central. Smoking Increases Postoperative Complications After Distal Radius Fracture Fixation: A Review of 417 Patients From a Level 1 Trauma Center The effect of diabetes is more nuanced. A large database analysis found that patients with diabetes had a low overall complication rate after distal radius surgery, with diabetes predicting only rare systemic problems like unplanned intubation and sepsis rather than the wound-healing and stiffness issues you might expect.29PubMed. Diabetes mellitus effect on rates of perioperative complications after operative treatment of distal radius fractures Another study found no significant difference in range of motion, grip strength, bone healing time, or functional outcomes between smokers and nonsmokers, complicating the picture somewhat.30PubMed Central. Influence of Smoking in the Clinical Outcomes of Distal Radius Fractures As with most surgical risk factors, the effect likely depends on how heavily someone smokes and what other health conditions are in play.
Surgeon experience also matters in a measurable way. A study that assessed outcomes by surgeon volume found that patients operated on by low-volume surgeons (performing fewer than eight volar locking plate cases during the study period) had a complication rate of about 27%, compared to roughly 7.5% for high-volume surgeons. Low volume was associated with nearly five times the risk of complications.31PubMed Central. Impact of surgeon volume on the risk of complications following volar locking plating of unstable distal radius fracture This is not unusual in orthopedic surgery; technical familiarity with plate positioning, screw length selection, and soft tissue handling improves with repetition. For patients, the practical implication is that choosing a surgeon who does a reasonable volume of these procedures is one of the few controllable factors that meaningfully shifts the odds.
When the Patient Is Still Growing
Children and adolescents bring a completely different set of concerns. Their bones have open growth plates near the wrist, and any fixation that crosses or damages these growth plates can disrupt normal bone development. A systematic review of pediatric distal radius fracture management emphasized that metaphyseal fractures (fractures of the wider part of the bone near the wrist) are primarily at risk for redisplacement and mechanical failure, while physeal fractures (those involving the growth plate itself) carry the added risk of growth disturbance and premature arrest. Hardware that crosses the growth plate introduces an iatrogenic threat that must be weighed carefully against the need to stabilize an unstable fracture.32SICOT-J. Management of pediatric distal radius fractures – A systematic review and meta-analysis In practice, this means pediatric surgeons lean toward minimally invasive fixation and accept slightly less perfect fracture alignment to avoid growth plate damage, a trade-off that would not make sense in an adult.