DISTAL RADIUS

FRACTURE
HUSNUL VERDIAN
EPIDEMIOLOGY

Frequency
 17% of all ER visits .
 Distal radial fractures account for 1/6 of all fractures seen in the ED
 Race: No racial preferences have been reported.
Age
Bimodal age distribution:
Peaks at ages 5-14 years
and at ages 60-69 years.
Elderly patients  extra-
articular, metaphyseal
Young patients  intra-
articular fractures with joint
surface displacement.

Gender
In older postmenopausal
women, female-to-male
ratio 4:1
but In adolescent boys and
girls, the ratio is 3:1
ANATOMY

• articular plateau upon which carpus rests

• gives origin of ligament which wrist joint stability rests
• also forms articulation with ulnar head combined with TFCC
• 3 concave articular facets
-scaphoid fossa
-lunate fossa
-sigmoid notch
ANATOMY
 TFCC major stabiliser of ulnar carpus & radioulnar joint
 normal wrist movement
-150 degree of motion (flex/ext)
 -50 deg radial/ulnar deviation
-150 deg pron/sup
 axial load-80% radius
-20% TFCC
MECHANISM OF INJURY

Low energy trauma: FOOSH

In young adult, injury usually is as result of high energy trauma &
results in comminuted, intraarticular injuries

Tension on the volar cortex, comminution of the dorsal cortex,

and ligamentous injury
DIAGNOSIS

• History
• Physical exam, look for other injury
injury should be evaluated for:-
• open/closed
• degree of soft tissue injury
• neurovascular injury- median nerve injury common

• Imaging
Wrist PA, Lat, and oblique
AP and lat. Of the contralateral wrist
Ct scan
RADIOGRAPHIC ASSESSMENT

 radial inclination
 volar tilt
 radial length
 Any intra-articular gap or step
SPECIFIC FRACTURE TYPES

 Colle's: Dorsal displacement (Abraham Colles (1773-1843), Irish

surgeon and anatomist)
Smith's: Volar displacement (Robert William Smith (1807-1873),
Irish surgeon)
Barton's: Radial rim fracture with dislocation of the radiocarpal
joint (can be dorsal or volar); John Rhea Barton (1794-1871)
American surgeon.
Chauffeur's: Radial styloid
CLASSIFICATIONS

 Classification system must consider type ,displacement and

severity of fracture
 should serve as basis for treatment & prognosis
 studies have shown that there is little interobserver agreement
• Andersen et al compared the Frykman, Melone, Mayo, and
AO/ASIF classification systems and concluded that a low
degree of intraobserver and interobserver agreement exists
in each of these 4 systems.
MANAGEMENT
TREATMENT GOALS

pain free, mobile and stable wrist.

 Anatomical reduction should be the goal
Howard,1989.
CRITERIA FOR ACCEPTABLE
REDUCTION
Graham1997(Jaaos) 1_Radial
shortening less than 5 mm at the distal radioulnar joint (DRUJ)
compared with the contralateral wrist.
2_Radial inclination of more than 15° on a posteroanterior (PA)
image.
3_Sagittal tilt on the lateral projection between 15° dorsal tilt and
20° volar tilt.
 4_Intra-articular fracture step-off less than 1-2 mm of the
radiocarpal joint

 Jupiter et al.
2mm or more of articular incongruity led to post-traumatic
arthritis
PREDICTORS OF STABILITY

 Associated Ulnar styliod #

 Age of the patient
 Extent of metaphyseal comminution
 Redisplacement after closed reduction is a predictor of
instability and repeated manipulation is unlikely will result in
successful radiological outcome
TREATMENT OPTIONS

 Closed reduction and immobilization

 Closed reduction and Percutaneous pinning
 External fixation
 Arthroscopically assisted reduction and Ex. Fixation of
intraarticular fracture.
 ORIF with plate fixation
 Bone grafting
 I. Nonarticular/  -cast immobilisation
undisplaced
 II Nonarticular/ 
displaced
A.reducible/stable
B.reducible/unstable  -cast immobilisation
C.Irreducible/stable -percutaneous pins
-ORIF/ex fix
 IIIArticular/
undisplaced  -cast immobilisation/
percutaneous pins
 IV Articular,displaced
A.reducible,stable
 -closed reduction &
B.reducible,unstable K wires
-A/A +/- ex fix
C.irreducible
-ORIF or
D.complex ex fix & K wires
-ORIF/ex fix & wires
+ bone graft
COMPLICATIONS

Malunion/ non union

DRUJ Complicatios ( Incongruent DRUJ)

Neurological Injuries
Medial, Ulnar, Complex regional pain syndrome
Tendon injuries
Infection.
TREATMENT COMPARSION
WHERE IS THE EVEDINCE??
• major questions remain:-
• (1) Is ex/fix or percutaneous pin fixation a better intervention
than CR when evaluated with validated outcome measures?
• (2) How does ORIF compare with ex/ fix and percutaneous pin
fixation or even CR and cast immobilization?
 (3) Is there a particular technique for each treatment modality
that provides superior results?
 (4) As most recent studies include only a maximum of two years
of follow-up, do the results of treatment endure over the long
term?
Recent randomized, controlled trials have begun to clarify some
of these questions!!
PERCUTANOUS PIN OR CLOSED
REDUCTION??
 Abela M et al. JBJS 2005
 In a study of 57 patients, radiographic parameters after
percutaneous pin fixation IN unstable extra-articular # were
found to be significantly better than those after closed reduction
(p < 0.05); however, there was no difference in SF-36 scores.
BRIDGING EX/FIX OR CR??

 YOUNG CF et al2003(J hand S) A series of 85 patients

demonstrated statistically equivalent Gartland and Werley
functional scores after seven years of follow-up; however,
radiographic measures were significantly better in the external
fixation group (p < 0.001).
 Kreder et al.(JOT)2006 .When validated outcome scores were
used to compare spanning external fixation with closed
reduction and cast immobilization of metaphyseal
displacment(DRF) without joint incongruity in 113 patients, SF -
36bodily pain scores and (MFA) scores at two years favored
external fixation.
AUGMENTED EXTERNAL FIXATION VERSUS PERCUTANEOUS PINNING
AND CASTING FOR UNSTABLE FRACTURES OF THE DISTAL RADIUS??

Harley et al. 2004(JHS)

similar validated outcome scores and functional outcomes at one
year, the patients treated with ex/fix demonstrated better
articular congruity on radiographic follow-up.
INDIRECT REDUCTION AND PERCUTANEOUS FIXATION VERSUS
OPEN REDUCTION AND INTERNAL FIXATION FOR DISPLACED INTRA-
ARTICULAR FRACTURES OF THE DISTAL RADIUS

 Kreder et al. 2005(JBJS)

 was compared in 179 patients although MFA and SF-36 scores at
two years were statistically equivalent between the groups,
EX/FIX yielded better outcomes at the six-month interval.
COMPARISON OF EXTERNAL AND PERCUTANEOUS PIN
FIXATION VERSUS PLATE FIXATION FOR INTRA-
ARTICULAR DISTAL RADIAL FRACTURES

• Frankie leung et al. 2008(JBJS) At the time of 24 month

follow-up, the results for the plate fixation group were
significantly better than those for the external fixation and
percutaneous pin fixation group according to the Gartland and
Werley point system (p = 0.04) and the radiographic arthritis
grading system (p = 0.01).The difference was especially notable
among patients with AO group-C2 fractures.
BRIDGING EXTERNAL FIXATION AND SUPPLEMENTARY
KIRSCHNER-WIRE FIXATION VERSUS VOLAR LOCKED
PLATING FOR UNSTABLE FRACTURES OF THE DISTAL
RADIUS

 K. Egol et al 2008(JBJS)
 No clear advantage could be demonstrated with either
treatment but fewer re-operations were required in the external
fixation group.
BRIDGING VERSUS NON-
BRIDGING EXTERNAL FIXATION ??
 M.McQueen1998(JBJS) noticed Non-bridging external fixation
is the treatment of choice for unstable fractures of the distal
radius which have sufficient space for the placement of pins in
the distal fragment.
THANK YOU ;)