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
fxs

A depressed fracture of the lunate fossa of the articular

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

Colles' fx

Low energy, dorsally displaced, extra-articular fx

Smith's fx

Low energy, volar displaced, extra-articular fx

Imaging

Radiographs
View
AP

LAT

Measurement

Normal

Radial height 13 mm

Acceptable criteria
<5 mm shortening

Radial
inclination

23 degrees change <5

Articular
stepoff

congruous

Volar tilt

dorsal angulation <5 or within 20 of

11 degrees contralateral distal radius

<2 mm stepoff

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 (prereduction 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