DISTAL RADIUS FRACTURE

ANAMNESIS

 Mekanisme cedera
 Riwayat cedera atau operasi wrist sebelumnya
 Anatomi abnormal, CTS, peripheral vascular disease

PX:

 Look: bengkak (bisa sudah berkembang/belum), deformitas, open fracture

 Feel: palpasi, CRT nail bed & fingertip
 Move:
 Status neurovascular: motoric sensorik median, radial, ulnar

Sensasi di thumb & index krn kompresi n. median akut sering tjd terutama dg fraktur displace
berat

RADIOLOGI

Is there loss of normal anatomy (eg, fracture displacement or angulation, loss of radial height)? (See
'Anatomic landmarks and measurements' below.)

●Is there involvement of the radiocarpal or distal radioulnar joint?

●If joints are involved, is there discontinuity of the articular surface (ie, articular step-off) or diastasis (ie,
separation) of the articular fragments?

●Are high-risk features present (eg, severe comminution, articular step-off >2 mm, fracture-dislocation)?

Posterior-anterior (PA) radiograph — Landmarks on the PA projection include the radial and ulnar
styloids, the distal radioulnar joint (DRUJ), and the radiocarpal joint, including the proximal carpal bones.
Important radiographic measurements include radial inclination, radial height, and ulnar variance.

●Radial inclination (image 1 and figure 2) is the angle between one line drawn perpendicular to the long
axis of the radius and a second line drawn between the distal tip of the radial styloid and the central
reference point (CRP). The CRP lies midway between the palmar ulnar corner and the dorsal ulnar
corner of the distal radius (image 2). The average angle is approximately 20 to 25 degrees, although
there are slight gender differences (24.7 ± 2.5 for women; 22.5 ± 2.1 for men) [13]. The angle is often
smaller with distal radius fractures.

●Radial height (image 1 and figure 2) is the distance between two lines drawn perpendicular to the
longitudinal axis of the radial shaft: one through the distal tip of the radial styloid and the second
through the CRP. Normal height averages 11.6 ± 1.6 mm [13]. The measured height is often smaller with
distal radius fractures.
●Ulnar variance (image 1 and figure 2) is the distance between two lines drawn perpendicular to the
longitudinal axis of the radial shaft: one through the distal articular surface of the ulnar head and the
second through the CRP. Normally, the radial surface is distal to the ulnar surface by 1 to 2 mm
(negative ulnar variance) [13]. When the ulnar surface is distal to the radial surface (positive ulnar
variance), the biomechanics of the wrist can be impaired, especially if the distance is 5 mm greater than
the contralateral wrist.

Lateral radiograph — In a true lateral projection (image 3), the radius and ulna should be superimposed,
and the pisiform projected over the distal pole of the scaphoid. If the pisiform is found dorsal to the
scaphoid, the patient is in relative pronation; if found palmar, the patient is in relative supination.
Normally, the lunate is seated within the fossa of the distal radius, and the curvature of their articular
surfaces should correspond. The central axis of the lunate should be collinear with the central axis of the
radius. Palmar migration is a sign of radiocarpal instability [13].

The most important measurement on a lateral projection is palmar tilt (ie, volar tilt). AP distance may
also be helpful.

●Palmar tilt (image 3 and figure 3) is the angle formed by the intersection of one line perpendicular to
the longitudinal axis of the radial shaft and a second line drawn through the apices of the palmar and
the dorsal rims of the radius. The normal palmar tilt on a standard lateral projection averages 11.2 ± 4.6
degrees and does not differ between genders [13]. A smaller palmar tilt as a result of fracture is a risk
factor for subsequent pain and disability.

●AP distance (image 3 and figure 3) lies between the apices of the dorsal and palmar rims of the radius.
Normally, AP distance should be slightly larger than the width of the lunate, and it averages 19.1 ± 1.7
mm. It is significantly larger in males (20.4 ± 1.1) versus females (17.8 ± 1.7) [13]. It can increase as a
result of axial impaction injuries and suggests articular step-off.

Klasifikasi

Banyak sistem, tidak ada yang universal. Bisa bds spesifik-fragmen atau standard Frykman. Frykman
mjd 4 grup bds keterlibatan sendi. Nomor genapmencakup fraktur styloid ulnar juga

 Tipe I/II: completely extraarticular, komplikasi jarang jika alignment anatomic telah tercapai
 Tipe III/IV: extend into radiocarpal joint
 Tipe V/VI: extend into distal radioulnar joint (DRUJ)
 Tipe VII/VIII: mencakup radiocarpal dan DRUJ articular surfaces dan sangat tidak stabil

2 eponim: Colles dan Smith. Colles dorsal displacement of the distal radius fragment. Smith: palmar
displacement distal radius fragment

Dislokasi fraktur 2 tipe utama dislokasi fraktur radiocarpal: Barton dan Hutchinson

 Barton dibagi menjadi palmar dan dorsal, dilihat paling bagus pd radiograf lateral.
 PalmarTerjadi ketika ligament radiocarpal palmar avulsiin fragmen radial dan displace unit
radiocarpal volarly.

Dorsalligamen radiocarpal dorsal avulsi fragmen radial dan displace unit radiocarpal dorsally

Di ke-2 tipeL fragmen radius distal tetap berartikulasi dengan carpus, berperan pada dislokasi
dan stabilitas.

Coba reduksi terututup sangat unstable dan reduction lost scr umum butuh fiksasi operasi

 Hutchinson/Chauffeur’s fracture mekanisme tipikal: benturan langsung ke styloid radial atau

jatuh ke punggung dengan tangan menjulur pada deviasi ulnar dan supinasi bikin ligament
radioscaphocapitate avulsi fagmen besar styloid radial dislokasi lunate concomitant/disosiasi
scapholunate

diagnosis definit berdasarkan x ray plain. Dari anamnesis dan px fisik

diagnosis banding

 fraktur scaphoid / tulang-tulang carpal

 cedera DRUJ/ kompleks triangular fibrokartilago
 cedera ligament gejala berbeda tergantung ligament (co: dislokasi lunate/perilunate,
disosiasi scapholunate)
 cedera scaphoid sering terjadi, sering terkait dengan nyeri di anatomic snuffbox (medial:
extensor pollicis longus tendon, lateral: extensor abductor pollicis longus tendon)

Indikasi konsul ortopedik atau rujuk:

 Fraktur terbuka
 Fraktur terkait neuropati akut atau sindrom kompartemen
 Fraktur terkait gangguan sirkulasi di tangan (mungkin butuh bedah vascular)
 Unstable fracture
 Risiko tinggi komplikasi
 Palmarly displaced (co: Smith)
 Articular stpe-off greater than 2mm
 Fraktur styloid ulnar besar (co, sebagian besar/semua styloid) dengan fragment displaced pada
dasar styloid; meningkatkan risiko instabilitas DRUJ
 Dislokasi fraktur (co. Barton/Hutchinson)
 Terkait fraktur scaphoid/cedera ligament scapholunate (fraktur styloid radial sering terkait
cedera scapholunate)
 Fraktur dengan displacement/kominutif signifikan unstable, cenderung lose position meski
dengna reduksi inisial near-anatomic
 Cenderung unstable dan unamenable thd conservative

Parameter instabilitas jarang disebutkan, tergantung usia dan kebutuhan fungsional.

 Radiologi suggests instabilitas dan butuh rujuk:

  Angulasi dorsal >20derajat
 Displacemenet fraktur pada arah apapun lebih dari 2/3 lebar radial shaft
 Kominusi metaphyseal dengan >5mm pemendekan radial (tinggi normal: 10-13mm)
 Variasi ulna >5mm disbanding wrist kontralateral (normal variance 0-(-2) mm
 Komponen intraarticular (terutama melibatkan DRUJ)
 Osteoporosis lanjut

Skoring untuk instabilitas ada macam2underestimate instabilitas fraktur tidak rekomendasi

Jika ada gangguan neurologi atau vascular, reduksi tertutup harus segera, setelah analgesic, untuk
mengurangi gejala. Kalau deficit tetap ada, rujuk ke bedah.

Talak awal

Recognition kondisi gawat!!!!!!!!!

Keputusan untuk reduksi tertutup

Jika cedera saraf signifikan (co: paralisis, kelemahan berat) atau gangguan vascular ada, reduksi tertutup
harus segera, setelah analgesic, untuk mengurangi gejala. Kalau deficit tetap ada, rujuk ke bedah.

Talak

Nondisplaced extra-articular fractures (Frykman I/II)

Relative stabil well-molded sugar tong, reverse sugar tong, atau double sugar tong splint

Beberapa hari pertama: elevasi, es (splint tetap kering), mulai active ROM bahu&jari, analgesic prn

Displaced fracture (Frykman I-VIII)

Dengan gangguan neurovascularusaha reduksi tertutup segera

Kriteria reduksi adekuat untuk pasien dengan kebutuhan fungsional tinggi:

No dorsal tilt permukaan articular radial distal

<5mm pemendekan radial

<2mm displacement fragmen fraktur

Apa itu

Tear drop angle

AP distane

Articular separation

Komplikasi awal?

Teknik dasar splinting cedera MSK

radiografi

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