Distal Radius Fractures in Adults – Introduction
Fractures in the distal part of the radius are very common injuries that can occur at almost any age. This kind of injury has a broad spectrum of varieties, and the management of this injury can range from non-surgical treatment to operative treatment, with newer techniques such as arthroscopy-assisted fixation. This article will provide crucial information for physicians to review these distinctions, to differentiate which injuries are an emergency, and the initial management and consequent treatment options.
Case example: A 65-year-old woman falls from her own height with her wrist hyperextended (Figure 1). In the trauma bay, radiographs confirm a displaced distal radius fracture. After proper temporary immobilization with a splint and a sling, open reduction and internal fixation surgery is scheduled in the next few days.
Figure 1. A lateral radiograph of the distal radius showing an extra-articular fracture with dorsal displacement and ulnar styloid fracture.
The radius is one of the two forearm bones. The proximal part of the bone articulates with the humerus and the ulna to compose the elbow joint. These two forearm bones are connected to each other through the interosseous membrane. The radius then widens at its distal part and articulates with the proximal row of the carpus (the scaphoid and the lunate bones) to form the wrist joint (or radiocarpal joint) with movement in the sagittal plane (flexion and extension) and coronal plane (adduction and abduction). And it also articulates with the distal ulna (the distal radioulnar joint), which is involved in the pronation-supination movement (axial plane).
Many soft structures as ligaments or tendons, originate or cross the wrist, and neurovascular structures, such as the radial and ulnar artery, the median, ulnar and radial nerves travel through the wrist to the hand.
Distal radius fractures are adults’ most common injury, accounting for approximately 17.5% of fractures . The incidence of these fractures follows a bimodal distribution: first peak in the pediatric and second peak in the elderly population. While in the pediatric population, the incidence is greater in males, fractures in the elderly population occur more frequently in females (2-3:1) .
While in the younger population, these injuries derivates from high-energy trauma, in the elderly, a fall on an outstretched hand is the most common mechanism of production. Newer studies show the worldwide incidence of distal radius fractures is increasing yearly owing to the overall potential to live longer with comorbidities such as osteoporosis .
Most distal radius fractures in the elderly population are produced by falling on an outstretched hand. In the younger, high-energy trauma is needed to fracture the bone.
Associated conditions include ulnar styloid fracture, distal radioulnar joint injuries, and ligamentous injuries: Triangular FibroCartilage Complex (TFCC) injuries, lunotriquetral ligament, and scapholunate ligament injuries.
There are many classification systems for these types of fractures.
One of the most used, the AO Classification (Table 1), divides fractures into extra-articular, partial intra-articular, and complete intra-articular . This classification includes a total of 27 subtypes of distal radius fractures, so the reliability and reproducibility can be lower .
Table 1. AO classification for distal radius fractures.
|2R3-A (extraarticular)||2R3-B (partial articular)||2R3-C (complete articular)|
|A1: radial styloid avulsion||B1: sagittal (Chauffer)||C1: simple articular and metaphyseal|
|A2: simple||B2: dorsal rim (Barton)||C2: comminuted metaphyseal|
|A3: wedge or multifragmentary||B3: volar rim (reverse Barton)||C3: multifragmentary articular|
Another widely used is also the Fernandez classification (Table 2), which is based on the mechanism of production. Different characteristic fracture patterns can occur depending on the position of the wrist and the deforming force. For example, if a flexion force is produced with the hand in flexion, the fracture will usually be extra-articular with volar displacement, called the Smith’s fracture. And if the wrist is in an extension position, the displacement will be in a dorsal direction, the well-known Colles’ fracture .
Table 2. Fernandez’s classification for distal radius fractures.
|Type 1. Bending fracture of the metaphysis||Extra-articular, can be stable or unstable. Variable comminution of the metaphysis. Dorsally displaced: Colles’ fracture or volarly displaced: Smith’s fracture (unstable).|
|Type 2. Shearing fracture of the joint surface||Partial intraarticular, a portion of the joint surface is in continuity with the metaphysis and shaft. Unstable patterns. Radial: Cheufeur’s. Dorsal: Barton’s. Volar: reverse Barton’s.|
|Type 3. Compression fracture of the joint surface||Complete articular, the joint surface is not in continuity with the metaphysis and shaft. It can be stable or unstable. Two, three, or four-part fractures.|
|Type 4. Avulsion fractures||Radiocarpal fracture-dislocation is frequently associated with other ligamentous injuries. Unstable pattern.|
|Type 5. Combined fractures||High-velocity injuries. Comminuted and/or bone loss. Associated injuries are always present.|
There are many distal radius fracture eponyms, including :
- Colles’s Fracture: an extra-articular fracture with dorsal displacement.
- Smith’s Fracture: an extra-articular fracture with volar displacement.
- Barton’s Fracture: a partial articular fracture with a volar fragment, displaced volarly. Reverse Barton’s fracture is a dorsal fragment displaced dorsally.
- Chauffer’s Fracture: a partial articular fracture with a radial styloid fracture, high energy.
- Die punch Fracture: an articular fracture, depressed fracture of the lunate fossa of the distal radius.
Usually consists of wrist pain, swelling, and deformation. The motion of the wrist and fingers can be limited by pain. For Colles’ fracture, the classic deformity is called “dinner fork deformity” (Figure 2) because of its reminiscence to the back of a fork.
In high-energy trauma, it is necessary to investigate for open fractures and must inspect the neurovascular status (radial and ulnar artery pulse, capillary filling, and status of the radial, median and ulnar nerves).
Assessment of associated injuries should include palpation of the elbow (Essex Lopresti injury), palpation and stress testing of the distal radioulnar joint, the anatomical snuffbox (occult scaphoid fracture), and the ulnar carpal region (distal ulnar fractures and TFCC injuries).
Figure 2. Dorsal displacement is seen in dorsally angulated distal radius fracture, creating a fork-like appearance. Image from page 732 of “The cyclopædia of anatomy and physiology” (1849) Todd, Robert Bentley, 1809-1860 (Public domain).
Radiographs are the first step to diagnosis and often the only one needed. Mandatory views include true AP and lateral views. The oblique view can help recognize hidden patterns. A break in the cortices of the bone should be seen, and associated bone injuries can also be diagnosed.
Radiographic parameters of the distal radius are measured in these two views. These include radial inclination (AP view), radial height (AP view), articular step-off (AP view), and volar tilt (lateral view) .
Table 3. Radiographic parameters of distal radius
|Radial inclination||22º||<5º of change|
|Radial height||10 mm||<5 mm of shortening|
|Volar tilt||11º||<5º of dorsal angulation|
|Articular step-off||0 mm||<2 mm|
For intraarticular fractures, a CT scan should be taken. It allows visualization and individualization of fragments, measurement of articular step-off, and surgical planning. MRI is taken when a soft-tissue injury is suspected, including TFCC and intercarpal or radiocarpal ligament injuries.
The initial treatment for any fracture is immobilization. In most cases, it can be achieved through closed manual reduction and the use of a splint or cast. For those fractures with joint steps of less than 2 mm, a dorsal tilt of fewer than 10 degrees or within 20° of contralateral radius, or radial shortening of less than 3 mm, non-surgical treatment can be performed .
The reduction maneuver consists of traction on the axis of the radius and counter traction at the level of the elbow, dorsal hyperextension to create space, and then flexion. The fracture can be immobilized using a sugar-clamp splint, or more commonly, a circular cast, with the wrist in slight palmar and ulnar flexion. The debate today is whether the elbow should be immobilized as well. The latest studies indicate no substantial differences between below-elbow and above-elbow casts in terms of fracture reduction maintenance or clinical outcomes .
After performing the closed reduction, new x-rays will be taken (Figure 3 and Figure 4). In the case of an inherently stable fracture with acceptable reduction, definitive treatment will consist of a cast for approximately 4-6 weeks, with weekly serial radiographic follow-up to determine that there are no secondary displacements within the cast. After this period of casting, movement of the wrist must start. A supervised physical therapy program is more effective for improving function in the short- and medium-term compared to a home exercises program in patients older than 60 years with extra-articular distal radius fractus without immediate complications .
Figure 3. Pre-reduction Lateral and AP radiographs of a distal radius fracture.
Figure 4. Post-reduction lateral and AP radiographs of distal radius fracture with a below-elbow cast.
One way to know if the fracture is inherently unstable is by using the LaFontaine criteria  in pre-reduction radiographs, which are:
- severe osteoporosis
- associated ulnar fracture
- dorsal comminution > 50%, palmar comminution, intraarticular comminution
- dorsal angulation > 20°
- initial displacement > 1cm
- initial radial shortening > 5mm
Lafontaine criteria are a predictor of instability. Radial shortening is the most important risk factor, followed by dorsal comminution. If three or more risk factors are encountered, the chance of reduction loss is higher; therefore, operative treatment should be considered.
Surgical treatment of radius fractures consists of three options: closed reduction and percutaneous pinning, open reduction and internal fixation, or external fixator.
Closed reduction and Percutaneous pinning
Closed reduction with percutaneous pinning modality is losing popularity as a treatment modality for distal radius fractures. However, in select cases, this technique may have advantages relative to open reduction and internal reduction . Indications are quite precise: highly displaced and unstable fractures in very young patients or extra-articular fractures with stable volar cortical bone in adults.
Kapandji’s intrafocal technique is the most used. It consists of placing two or three pins inside the fracture gap. One pin goes from dorsal to volar and is utilized for achieving the volar angulation, and another from radial to ulnar and is used for acquiring radial inclination and radial height. These pins are employed as a lever for fracture reduction, and once a good reduction is achieved, the pins are driven until they engage the opposite cortex . Other techniques are extrafocal, starting from one fragment to another across the fracture; generally, one pin through the radial styloid and the other parallel to the articular surface of the radius, engaging the distal ulnar cortex .
Complications of this technique include pin tract infection and nerve damage (especially radial sensory nerve in the radial styloid site).
Open Reduction and Internal Fixation (ORIF)
The most widely used treatment nowadays is open reduction and internal fixation with a plate. New techniques and new plate designs have made it possible to obtain very good results, supporting the subchondral bone without collapse, a solid structure that maintains fracture reduction and also allows early mobilization.
Indications include radiographic findings indicating instability (the LaFontaine criteria), displaced intra-articular fractures greater than 2mm, articular margin fractures (Barton’s fracture), extra-articular with volar displacement (Smith’s fracture), the Die Punch fracture, or progressive loss of volar tilt and radial length following casting.
Commonly, a volar approach (the modified Henry’s approach) is used, and a volar plate with locking screws is preferred (Figure 5). Some fracture patterns, such as reverse Barton (a partial articular dorsal fragment) or multi-fragmentary articular fractures, may require a dorsal approach and the placement of specific fragment plates. Another advantage of open reduction and internal fixation is the possibility of placement of autologous bone graft or phosphocalcic cement, which are indicated in fractures with bone loss, great comminution, or in cases of malunion . And in recent years, arthroscopy-assisted reduction of articular fractures has become very popular, which among its advantages, allows direct visualization of the joint, minimizing the risk of residual articular step-off and the simultaneous treatment of concomitant injuries such as intercarpal ligamentous injuries or TFCC injuries .
Figure 5. ORIF of distal radius fracture with a volar locking plate.
Complications of ORIF include tendon rupture (FLP or EPL) and malposition of screws (intraarticular screws).
Indications for external fixation include open fractures and highly comminuted fractures, which require a joint-spanning procedure . In other medical centers, external fixation is usually done combined with percutaneous pins for restoration of palmar tilt and radial length in comminuted articular fractures . Complications of this method include stiffness, pin tract infection, malunion and nonunion.
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