Distal Radius Fractures

Author: Mark Vitale

Topic updated on 05/13/15 11:48pm
Introduction

Most common orthopaedic injury with a bimodal distribution

o younger patients - high energy

o older patients - low energy / falls

50% intra-articular

Associated injuries

o DRUJ injuries must be evaluated

o radial styloid fx - indication of higher energy

Osteoporosis

o high incidence of distal radius fractures in women >50

o distal radius fractures are a predictor of subsequent fractures

DEXA scan is recommended in woman with a distal radius

fracture

Classification

Fernandez: based on mechanism of injury

Frykman: based on joint involvement (radiocarpal and/or radioulnar) +/-

ulnar styloid fx

Melone: divides intra-articular fxs into 4 types based on displacement

 AO: comprehensive but cumbersome

Eponyms: see table for list of commonly used eponyms

Eponyms
Die-punch A depressed fracture of the lunate fossa of the articular
fxs surface of the distal radius
Barton's fx Fx dislocation of radiocarpal joint with intra-articular fx
involving the volar or dorsal lip (volar Barton or dorsal
Barton fx)
Chauffer's fx Radial styloid fx x
Colles' fx Low energy, dorsally displaced, extra-articular fx
Smith's fx Low energy, volar displaced, extra-articular fx

Imaging

Radiographs

View Measurement Normal Acceptable criteria

AP Radial height 13 mm <5 mm shortening

Radial
23 degrees change <5
inclination
Articular
congruous <2 mm stepoff
stepoff
dorsal angulation <5 or within 20 of
LAT Volar tilt 11 degrees contralateral distal radius

CT scans

o important to evaluate intra-articular involvement and for surgical

planning

MRI useful to evaluate for soft tissue injury

o TFCC injuries
 o scapholunate ligament injuries (DISI)

o lunotriquetral injuries (VISI)

Treatment

Successful outcomes correlate with

o accuracy of articular reduction

o restoration of anatomic relationships

o early efforts to regain motion of wrist and fingers

Nonoperative

o closed reduction and cast immobilization

indications

extra-articular

<5mm radial shortening

dorsal angulation <5 or within 20 of contralateral

distal radius

technique (see below)

Operative

o surgical fixation (CRPP, External Fixation, ORIF)

indications: radiographic findings indicating instability (pre-

reduction radiographs best predictor of stability)

displaced intra-articular fx
 volar or dorsal comminution

articular margins fxs

severe osteoporosis

dorsal angulation >5 or >20 of contralateral distal

radius

>5mm radial shortening

comminuted and displaced extra-articular fxs (Smith's

fx)

progressive loss of volar tilt and loss of radial length

following closed reduction and casting

associated ulnar styloid fractures do not require

fixation

Closed reduction and cast immobilization

Indications

o most extra-articular fxs

Technique

o rehabilitation

no significant benefit of physical therapy over home

exercises for simple distal radius fractures treated with cast
immobilization

Outcomes
 o repeat closed reductions have 50% less than satisfactory results

Complications

o acute carpal tunnel syndrome

(see complications below)

o EPL rupture

(see complications below)

Percutaneous Pinning

Indications

o can maintain sagittal length/alignment in extra-articular

fxs with stable volar cortex

o cannot maintain length/alignment when unstable or comminuted

volar cortex

Techniques

o Kapandji intrafocal technique

o Rayhack technique with arthroscopically assisted reduction

Outcomes

o 82-90% good results if used appropriately

External Fixation

Indications

o alone cannot reliably restore 10 degree palmar tilt

therefore usually combined with percutaneous pinning

 technique or plate fixation

Technical considerations

o relies on ligamentotaxis to maintain reduction

o place radial shaft pins under direct visualization to avoid injury to

superficial radial nerve

o nonspanning ex-fix can be useful if large articular fragment

o avoid overdistraction (carpal distraction < 5mm in neutral position)

and excessive volar flexion and ulnar deviation

o limit duration to 8 weeks and perform aggressive OT to maintain

digital ROM

Outcomes

o important adjunct with 80-90% good/excellent results

Complications

o malunion/nonunion

o stiffness and decreased grip strength

o pin complications (infections, fx through pin site, skin difficulties)

o neurologic (iatrogenic injury to radial sensory nerve, median

neuropathy, RSD)

ORIF

Indications

o significant articular displacement (>2mm)

o dorsal and volar Barton fxs

 o volar comminution

o metaphyseal-diaphyseal extension

o associated distal ulnar shaft fxs

o die-punch fxs

Technique

o volar plating

volar plating preferred over dorsal plating

volar plating associated with irritation of both flexor and

extensor tendons

rupture of FPL is most common with volar plates

associated with plate placement distal to watershed

area, the most volar margin of the radius closest to
the flexor tendons

new volar locking plates offer improved support to

subchondral bone

o dorsal plating

dorsal plating historically associated with extensor tendon

irritation and rupture

dorsal approach indicated for displaced intra-articular distal

radius fracture with dorsal comminution

o other technical considerations

can combine with external fixation and PCP

 bone grafting if complex and comminuted

study showed improved results with arthroscopically

assisted reduction

volar lunate facet fragments may require fragment specific

fixation to prevent early post-operative failure

Complications

Median nerve neuropathy (CTS)

o most frequent neurologic complication

o 1-12% in low energy fxs and 30% in high energy fxs

o prevent by avoiding immobilization in excessive wrist flexion

o treat with acute carpal tunnel release for:

progressive paresthesias

paresthesias do not respond to reduction and last > 24-48

hours

Ulnar nerve neuropathy

o seen with DRUJ injuries

EPL rupture

o nondisplaced distal radial fractures have a higher rate of

spontaneous rupture of the extensor pollicis longus tendon

extensor mechanism is felt to impinge on the tendon

following a nondisplaced fracture and causes either a
mechanical attrition of the tendon or a local area of
ischemia in the tendon.
 o treat with transfer of extensor indicis proprius to EPL

Radiocarpal arthrosis (2-30%)

o 90% young adults will develop symptomatic arthrosis if articular

stepoff > 1-2 mm

o may be nonsymptomatic

Malunion and Nonunion

o Intra-articular malunion

treat with revision at > 6 weeks

o Extra-articular angulation malunion

treat with opening wedge osteotomy with ORIF and bone

grafting

o Radial shortening malunion

radial shortening associated with greatest loss of wrist

function and degenerative changes in extra-articular fxs

treat with ulnar shortening

ECU or EDM entrapment

o entrapment in DRUJ injury

Compartment syndrome

RSD/CRPS

o AAOS 2010 clinical practice guidelines recommend vitamin C

supplementation to prevent incidence of RSD postoperatively