June 17 2009

Asim Makhdom
 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
• 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
 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
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
• 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
 radial inclination
 volar tilt
 radial length
 Any intra-articular gap or step
 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
 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.
 pain free, mobile and stable wrist.
 Anatomical reduction should be the goal
Howard,1989.
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
 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
 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  -cast immobilisation
B.reducible/unstable -percutaneous pins
C.Irreducible/stable -ORIF/ex fix
 IIIArticular/  -cast immobilisation/
undisplaced percutaneous pins
 IV Articular,displaced
A.reducible,stable  -closed reduction &
K wires
B.reducible,unstable -A/A +/- ex fix

C.irreducible -ORIF or
ex fix & K wires
D.complex -ORIF/ex fix & wires
+ bone graft
Malunion/ non union

DRUJ Complicatios ( Incongruent DRUJ)

Neurological Injuries
Medial, Ulnar, Complex regional pain
syndrome
Tendon injuries
Infection.
• 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!!
 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.
 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.
 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.
 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.
• 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.
 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.
 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.