DISTAL RADIUS
FRACTURE
Lê Ngọc Quyên
ATO
Anatomy
ATO
2 inches (5cm)
Mechanism Of Injury
Children and old women: low energy
trauma : simple fracture
Young adult: high energy trauma :
comminuted, intraarticular fracture
Diagnosis
History
Physical exam:
• open/closed
• degree of soft tissue injury
• neurovascular injury
Imaging
Wrist PA, Lat
CT scan
MRI
Radiographic Assessment
Extensor carpi
ulnaris tendon
groove
Smithuis:
Supination/Pronation 100
DA changes 50
RA : Radial angulation(radial
inclination, ulnar inclination…)
RL : Radial length ( radial height )
Intra-articular gap or step
DA : Dorsal angulation(volar tilt,
palmar tilt, dorsal tilt…)
UV : Ulnar variance
RA RL DA UV
Graham 220 12mm 110 -2mm
LNQ 230 11mm 90 -0.8mm
P<0.05
Specific fracture types
• Dorsal displacement (Abraham Colles
(1773-1843), Irish surgeon and anatomist)
Smith’s
Colles’ fracture
Specific fracture types
Volar displacement (Robert William Smith
(1807-1873), Irish surgeon)
Barton's:
Smith’s fracture
Specific fracture types
Radial rim fracture with dislocation of the
radiocarpal joint (can be dorsal or volar);
John Rhea Barton (1794-1871) American
surgeon.
Chauffeur's:
Volar Barton’s fracture Dorsal Barton’s fracture
Specific fracture types
Radial styloid :
Chauffeur’s fracture
Specific fracture types
Lunate load fracture : “Die punch” fracture
Classifications
• Classification system must consider type ,
displacement and severity of fracture
• should serve as basis for treatment &
prognosis
Many classfication systems: Frymann,
Fernandez, Melon, AO….
Fernandez classification: Fractures of distal radius classified by
mechanism of injury. I, Bending. II, Shear. III, Impaction. IV, Avulsions with
fracture-dislocation. V, High velocity.
Frykman's classification. Types I, III, V, and VII do not have
an associated fracture of the distal ulna. Fractures III through VIII
are intra-articular fractures.
Columnar classification
AO classification
Treatment Goals
Criteria for acceptable reduction
Graham 1997
Radial shortening : < 5 mm
Radial angulation : > 15°
Dorsal angulation : - 200 to + 150
Intra-articular fracture step-off : < 1-2 mm
Predictors of stability (AO)
( unstable fracture)
• Dorsal comminution exceeding >50% of the
dorsal to palmar distance
• Palmar metaphyseal comminution
• Initial dorsal angulation > +20°
• Initial displacement (fragment translation) >1 cm
• Initial shortening > 5 mm
• Intra-articular disruption
• Associated ulnar fracture
• Massive osteoporosis.
Treatment options
• Closed reduction and cast immobilization
• Closed/Open reduction and percutaneous pinning
• Kapandji intrafocal technique
• ORIF with plate fixation (+/- pinning)
• External fixation (+/- pinning)
• Arthroscopically assisted reduction and fixation of
intraarticular fracture.
• Bone grafting
Closed reduction and cast immobilization
Closed / Open reduction and percutaneous pinning
Kapandji intrafocal technique
Volar approach Dorsal approach
ORIF with plate fixation
(+/- pinning)
Bridding EF
Augmented EF
Non-Bridding EF
External fixation
Dynamic EF
External fixation
1977 : Vidal : “Ligamentotaxis”
Volar ligaments : many, thick, short
Dorsal ligaments: few, thin, long
Can not reduce DA
External fixation (+/- pinning)
Pre op After closed reducion +EF: 3mm articular step
Grafting bone+pinning 2 years Post Op
External fixation + pinning + Grafting bone
there is persistent gap deformity
fluoroscopic views after reduction and fixation, along the entire fracture line, with a
suggesting an good anatomic articular reduction displacement of 2 mm
Arthroscopically assisted reduction and
fixation of intraarticular fracture
Complications
Infection
Malunion
Incongruent DRUJ
Neurological Injuries: Medial, Ulnar
Complex regional pain syndrome
Tendon injuries
Question
1. All below are true regarding unacceptable reduction for a
distal radius fracture except:
a. Radial shortening : > 5 mm
b. Radial angulation : < 15°
c. Dorsal angulation : > +150
d. Intra-articular fracture step-off : < 1-2 mm
2. Which of the following is true regarding the external
fixation?
a. relies on ligamentotaxis to maintain reduction
b. usually combined with percutaneous pinning
technique or plate fixation
c. cannot reliably restore dorsal angulation
d. all above
3. A 32-year-old worker sustains a distal radius fracture.
Radiographs are provided below. What is the appropriate
treatment?
a. Closed reduction and long cast
b. Closed reduction and percutaneous pinning
c. Open reduction and plate fixation
d. Open reduction and external fixation
Anwser:
1. D
2. D
3. C
