Distal Radius Fractures: Treatment Options

Melvin P. Rosenwasser, MD
Robert E. Carroll Professor of Hand Surgery
Chief, Orthopaedic Hand, Trauma Services
Director, Trauma Training Center
Columbia-Presbyterian Medical Center

Introduction
● Goal: recovery of normal function: restore natural bow of the radius to maintain motion and
grip strength
normalization of length
axial alignment
rotational alignment
● Evaluation
Neuro-vascular exam
Compartment syndrome of the forearm can occur secondary to injury
Tense swelling, pain with passive motion, paresthesias
Forearm fasciotomy
● Radiographs
AP, lateral, oblique [also include wrist, elbow, with special attention to DRUJ.
● Etiology
High energy trauma: MVA, fall from height, GSW

Anatomy
● Articulation of the distal radius with the scaphoid and lunate bones of the carpus
The distal radioulnar joint (DRUJ)
Articulation of distal ulna with the triangular fibrocartilage complex (TFC)
The TFC articulates with both the lunate and the triquetrum of the carpus. The
scaphoid and lunate fossa are two concave articular surfaces separated by a dorso-
volar ridge. A third concave articulation, the sigmoid notch, exists for the head of the
ulna.
The contact area with the TFC varies with changing degrees of rotation of the wrist.
The amount of force transmitted between the TFC and the radius therefore varies with
changing degrees of pronation and supination. In supination, the ulnar head displaces
volarly in the sigmoid notch, while in pronation it rotates dorsally.
● Normal Anatomy: Distal Radius
Radial inclination angle: 23 degrees (AP x-ray)
Volar tilt (palmar inclination angle): 10 degrees (Lateral x-ray)
Ulnar variance (radial length): mean -0.9 mm (AP x-ray)
Classification
● AO/ASIF classification of diaphyseal forearm fracture patterns
Open fracture
Ratio of open fractures to closed is higher for forearm than other bones except tibia
Increased incidence of nerve laceration
Debridement, irrigation, rigid fixation
ORIF within 24 hours: external fixation, intramedullary nailing, or plating antibiotics
Prevention of infection is necessary to avoid malunion, nonunion, loss of function and
amputation
Comminuted fracture
Standard plating
Lag-screw fixation of the pieces
Defect can be bone grafted
● Frykman Classification System
8 categories
Considers ulnar styloid
Does not consider direction or amount of displacement of fracture fragments
AO Classification System
27 total fracture patterns
Highly detailed but unwieldy for easy use and memorization
● Melone Classification System
Applicable only to intra-articular fractures
Helpful in understanding the ‘die-punch’ lesion
● The Problem with Classification Systems
Andersen DJ, Blair WF, Steyers CM Jr, Adams BD, el-Khouri GY, Brandser EA.
Classification of distal radius fractures: an analysis of interobserver reliability and
intraobserver reproducibility. J Hand Surg 1996;21A(4):574-82.
Analyzed inter/intra observer agreement for Frykman, AO, Melone, and Mayo systems
None of the systems showed substantial interobserver agreement

Instability
● Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury
1989;20(4):208-10.
● La Fontaine (1989) criteria:
Dorsal tilt >20 degrees
Dorsal comminution
Intra-articular fracture
Associated ulnar fracture
Age over 60 years
● 3 or more tended to collapse

Treatment Options
● Tools to work with in achieving best reduction
Plaster
Pins
External fixation
Plates
Screws
Bone graft or filler
Arthroscopy

Criteria for Acceptable Reduction

● Change in volar (palmar) tilt < 10° (ie, neutral or 20 palmar slope)
● Radial shortening < 2 mm
● Change in radial angle < 5°
● When intra-articular fracture is present:
Articular step-off < 1-2 mm

Rationale for the Guidelines

● Intra-articular step-off
Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young
adults. J Bone Joint Surg 1986;68A(5):647-59.
2 mm step-off on AP x-ray greatly increased the risk of symptomatic osteoarthritis at
7 year follow-up
Dorsal tilt and radial length not much affect on outcome

Intra-Articular Incongruency
● Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced
intra-articular distal radius fractures. J Hand Surg 1994;19A(2):325-40.
3 year follow-up of 52 fx’s
Single most important factor that correlated with outcome was intra-articular gap
between fragments
Residual loss of volar or radial tilt did not correlate with outcome
● Catalano LW 3rd, Cole RJ, Gelberman RH, Evanoff BA, Gilula LA, Borrelli J Jr. Displaced
intra-articular fractures of the distal aspect of the radius. Long-term results in young adults
after open reduction and internal fixation. J Bone Joint Surg 1997;79A(9):1290-302.
7 year follow-up of 26 fx’s
All treated with surgery
Residual articular displacement (CT scan and x-ray) correlated with radiographic changes
but not with functional outcome

What is Important?
● Does the fracture extend to the opposite cortex of the radius?
 i.e., volar cortex for Colles
● Percutaneous fixation alone
Extra-articular fracture
Younger patient (good bone stock)
Good soft tissue envelope
Need adjunctive cast/brace
● ‘Kapandji’ Intrafocal Pinning
A technique of K-pinning using the pin itself to buttress the fracture site; usually requires
ex-fix or cast
● Pin Placement
Pins are placed avoiding any contact with flexor tendons

Contraindications
● Significant intra-articular displacement
● Volar cortical comminution
● Inability to obtain an anatomic reduction

Clinical Results
● Greatting MD, Bishop AT. Intrafocal (Kapandji) pinning of unstable fractures of the distal
radius. Orthop Clin of North America 1993;24(2):301-7.
23 patients, 24 unstable fx of distal radius
2 to 3 0.062 K-wires maintained for 4 weeks
6 weeks Short Arm Cast
Results:
Patients < 65 years of age
79% good or excellent radiologic results
Patients > 65 years of age
60% good or excellent radiologic results
UNION IN ALL PATIENTS
● Trumble TE, Wagner W, Hanel DP, Vedder NB, Gilbert M. Intrafocal (Kapandji) pinning of
distal radius fractures with and without external fixation. J Hand Surg 1998;23A(3):381-94.
Trumble TE, et.al. J Hand Surg 1998;23A(3):381-94
73 patients
Kapandji pinning with or without ex fix
All had dorsally displaced extra-articular fx
Results:
Older patients
Range of motion, grip strength & pain relief significantly better w/ ex fix
Younger patients
w/ comminution of only 1 surface
Good results w/ Kapandji pinning alone
w/ comminution of > 2 sides
 Better results w/ ex fix
● Stoffelen DV, Broos PL. Closed reduction versus Kapandji-pinning for extra-articular distal
radial fractures. J Hand Surg 1999;24B(1):89-91.
98 patients with extra-articular distal radius fractures
Prospective randomized trial
Results
Closed Reduction and Plaster Cast Group
74% good, excellent Cooney score
Kapandji-Pinning Group
75% good, excellent Cooney score

Volar Plating with Extra-articular plates

1. Approach
Make longitudinal incision slightly radial to the flexor carpi radialis tendon
(FCR). Dissect between FCR and radial artery.
2.

External Fixation
● ‘Ligamentotaxis’ pulls on the fracture fragments to reduce and prevent collapse
● Cannot restore normal volar tilt by pulling straight distally alone, a palmar vector is required
● External Fixation Advantages
Easy to apply
Access to wound/pins
‘Neutralizes’ fracture site
Frees up the elbow
Light
● External Fixation Disadvantages
Does not necessarily reduce the fracture alone
Possible pin-tract infection
? more stiffness with excessive distraction

Non-Joint Spanning Ex-Fix: What’s New?

● Indications
Unstable extra- or intra-articular distal radius fractures (DRF)
Failed closed reduction
Distal fragment size ≥ 6mm
McQueen recommends ≥ 10mm
Young patient
Good bone stock
● Treatment Options
Closed reduction - cast
Percutaneous pinning - cast
 Pinning - ExFix
ORIF
Dynamic ExFix
Non-joint spanning ExFix
● Patient’s Trauma
30 year old male sustained right distal radius fracture while snowboarding
Injury occurred 10 days prior to operation
X-ray reveals a minimally displaced right distal radius fracture with a noticeably
depressed lunate fossa as well as loss of volar tilt.

Benefits (Non-joint spanning ExFix)

● Rigid anatomic fixation
● Early motion
● Normal carpal load transfer / mobility
● Avoids late stiffness (no ligamentotaxis)

Technical Considerations
● What I use
● Standard proximal pins placement
● Mini C-arm to place distal pins
● Transverse pin placement
● Pins as joy-sticks to control fragment
● Radio-ulnar & volar-dorsal translation
● Both pins dorsally
● Supplement with percutaneous K-wires
● No ligamentotaxis = less stiffness?

Postop Care
● ROM after resolution of postop pain
● Interval splinting for 2-4 weeks
(prevent pin tract infection)
Fischer T, Koch P, Saager C, Kohut GN. The radio-radial external fixator in the
treatment of fractures of the distal radius. J Hand Surg 1999;24B(5):604-9.

Patient’s Trauma
● 46 year old male sustained injury from a fall while roller skating
Sustained markedly displaced, comminuted and impacted fracture of the left distal radius
metaphysis with intraarticular extension.
Closed reduction failed to maintain alignment
 There was a radial neurapraxia of his left thumb and marked instability with displacement
of his distal radius.

Clinical Studies
● Melendez EM, Mehne DK, Posner MA. Treatment of unstable Colles’ fractures with a new
radius mini-fixator. J Hand Surg 1989;14A(5):807-11.
13 cases
All extra-articular fractures
All healed by 8.5 weeks
Loss of radial length 0.5mm
Loss of palmar tilt 2.2 degrees
Loss of inclination 1.3 degrees
● Bishay M, Aguilera X, Grant J, Dunkerley DR. The results of external fixation of the radius
in the treatment of comminuted intraarticular fractures of the distal end. J Hand Surg
1994;19B(3):378-83.
14 cases
79% excellent / 21% good results
12/14 anatomic X-Ray
2 patients with <2mm step-off
● McQueen MM. Redisplaced unstable fractures of the distal radius: a randomised,
prospective study of bridging versus non-bridging external fixation. J Bone Joint Surg
1998;80B(4):665-9.
Prospective randomized study, 60 cases
Significant improvement:
Radiographic measurements
Functional outcome
Results maintained at 1 year
● Krishnan J, Chipchase LS, Slavotinek J. Intraarticular fractures of the distal radius treated
with metaphyseal external fixation. J Hand Surg 1998;23B(3):396-9.
22 cases (all intra-articular fractures)
Functional ROM at 4 weeks post fixator removal
● McQueen MM, Simpson D, Court-Brown CM. Use of the Hoffman 2 compact external
fixator in the treatment of redisplaced unstable distal radial fractures. J Orthop Trauma
1999;13(7):501-5.
20 cases
Postop:
Volar tilt 4 degrees
Radial shortening 1mm
Grip strength 74% contralateral limb
ROM 80%
1 loss of fixation (dorsal angulation)
● Fischer T, Koch P, Saager C, Kohut GN. The radio-radial external fixator in the treatment of
fractures of the distal radius. J Hand Surg 1999;24B(5):604-9.
 17 cases
29 months follow-up findings (avg):
Radial inclination 24 degrees
Volar tilt 12 degrees
Radial length 0mm

Complications
● Pin tract infections
increased skin mobility
volar interval splinting recommended
Fischer JHS (B) 1999
● Sensory nerve injury
Nerve more vulnerable with distal radial pins
Small skin incision recommended
McQueen J Orthop Trauma (1999)
● Nonunion
● Malunion
May be used after radial osteotomy for malunion
Posner JHS (1989)
● Extensor rupture
● Carpal tunnel syndrome
● RSD

Conclusion Non-joint Spanning Ex Fix

● Unstable intra- and extra-articular fractures
● Distal fragment at least 6mm length
● Young patient or good bone stock
● Avoids ligamentotaxis
● Early motion
● Late results same or better

Full Open Reduction & Internal Fixation

● The primary indication is severe articular displacement, which if left untreated, may lead to
radioulnar or radiocarpal arthritis.

Plates
● Volar buttress plating recommended for fractures that displace volarly
Usually the distal screw holes are left open
● Dorsal Plating
Recommended by some in lieu of ex-fix and K-pins
 Requires extensive dissection
Early motion usually not possible anyway
Plates usually require removal

Specific Conditions and Treatment

● Barton’s Fracture
Palmar Barton
Ideally treated by a palmar buttress plate.
Dorsal Barton (intra-articular Colles)
Best treated by closed reduction and external fixation if adequate reduction can be
maintained.
Otherwise, open reduction and percutaneous pins, compressive screws, or a dorsal
buttress plate can be used.
Arthroscopic reduction of dorsal Barton’s fracture offers an alternative that limits
exposure of the dorsal carpus and that may help maintain blood supply to the dorsal
fracture components. Skill in arthroscopy is required for this procedure.
● Smith’s Fracture
Open reduction and internal fixation (or external fixation) is the treatment of choice for
palmar displaced fractures.
External fixation for open Smith’s fractures is acceptable for wound considerations.
It is rarely necessary to have distal screws in using the buttress plate for most Smith
fractures, and there is risk of screws penetrating either the radiocarpal joint or extruding
dorsally to affect the wrist and finger extensor tendons. A mini fragment plate is the
exception to the general rule.
● Both-bone forearm fracture
ORIF within 48 hours of injury
Best achieved with 3.5mm compression plating, which is not removed after fracture
healing.
● Galleazzi fracture. “fracture of necessity”
Disruption of the DRUJ
Occurs in 3-6% of forearm fractures
Axial loading upon pronated forearm
Key features are isolated distal radius fracture with:
ulnar styloid fracture
widened DRUJ on AP of wrist
apex dorsal fracture and subluxation/dislocation of radius on
ulna (lateral view)
shortened distal radius >5mm relative to distal ulna
ORIF: radius is plated through an anterior approach. If the ulnar head is stable, the arm is held in
supination for 4 weeks. If the head remains unstable, it is pinned to the radius for 4 weeks. If the
RU is unreducible, the joint should be opened dorsally, inspected for interposed tendon or loose
bodies and reduce.

Outcomes and Complications

● ORIF with 3.5mm dynamic compression plate achieves a union rate of 95-98%
● Schemitsch and Richards (1992)
demonstrated 84% of patients managed with plating had an excellent, good or acceptable
functional result 6 years post-op.
Restoration of the normal radial bow was related to the functional outcome.
A good functional result (more than 80% of normal rotation of the forearm) and recovery
of grip strength were associated with restoration of the normal amount and location of the
radial bow.
● Complications
related to the severity and classification of the fracture.
Chapman, et al (1989)
demonstrated a rate of 13% for nerve injuries (9% radial, 2% median, 2% ulna) and
2% incidence of vascular injuries.
Radioulnar synostosis has been reported in 2% of forearm fractures (Vince, 1987)
Complication of a Galleazzi fracture:
nerve injury to the dorsal sensory branch of the radial nerve
Operative vs. Nonoperative management in the elderly

Egol KA, Walsh M, Romo-Cardoso S, Dorsky S, Paksima N. Distal radial fractures in the
elderly: operative compared with nonoperative treatment. J Bone Joint Surg Am.
2010;92(9):1851-1857.

Case/control w/ 90 patients > 65 y/o, 82 treated operatively / 74 treated non operatively

initially treated with closed reduction / splinting
surgical management: volar locked plate or bridging external fixation
nonsurgical management: treated until healing via cast immobilization
24 week f/u: surgical cohort showed better wrist extension
1 year f/u: no difference in wrist extension, but grip strength better for surgical
management
At all follow-ups: No difference is seen in DASH or pain scores
No difference between groups with regard to complications

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