Distal Radius Fractures

Distal Radius
• Fractures
Common injury
• Fractures of the distal radius represent approximately 16% of all
fractures treated by orthopaedic surgeons
• Three main peaks of fracture distribution:
• children age 5-14
• males under age 50 (High velocity)
• females over the age of 40 years (Low velocity)
• Elderly (Most, extrarticular)
• Young (Most, intra articular)
• Elderly patient risk factors : Decreased bone mineral density,
female gender and early menopause
• High potential for functional impairment and frequent complications
 Introduction
• Distal radius fractures occur through the distal
metaphysis of the radius
• May involve articular surface frequently involving
the ulnar styloid
• Most often result from a fall on the outstretched
hand.
– forced extension of the carpus,
– impact loading of the distal radius.
• Associated injuries may accompany distal radius
fractures.
 Introduction

Classified by:
– presence or absence of
intra- articular involvement,
– degree of comminution,
– dorsal vs. volar
displacement,
– involvement of the distal
radioulnar joint.
 Diagnosis: History and
Physical
• Findings
History of mechanism of injury
• A visible deformity of the wrist is usually noted, with the hand most
commonly displaced in the dorsal direction. (90% cases)
• The acute shortening of the radius relative to the ulna may manifest as
an open wound palmarly and ulnarly where the intact ulna
buttonholes through the skin.
• Movement of the hand and wrist are painful.
• Adequate and accurate assessment of the neurovascular status of the
hand is imperative. (Median nerve involvement – Carpal tunnel
syndrome)
 Diagnosis: Diagnostic
Tests and
Examination
• Evaluation of the injured joint, and a joint above and
below (ipsilateral elbow & shoulder joint)
• Radiographs of the injured wrist (PA & Lateral)
• Radiographs of other areas, if symptoms warrant.
• CT scan of the distal radius in selected instances.
 Treatment Goals
• Preserve hand and wrist function

• Realign normal osseous anatomy

– Articular surface

• Promote bony healing

• Allow early finger and elbow ROM

 Osseous Anatomy
Distal radius – 80% of axial load
– Scaphoid fossa
– Lunate fossa

Distal ulna – 20% axial load

Sigmoid notch – DRUJ

 Anatomy
scaphoid and lunate fossa
– Ridge normally
exists between
these two
sigmoid notch:
second important
articular
surface
triangular fibrocartilage
complex(TFCC):
distal edge of radius to
Classification of Distal
Radius Fractures
Ideal system should describe:
– Type of injury
– Severity
– Evaluation
– Treatment
– Prognosis
Common
Classifications
1.Gartland & Werley
2.Frykman (radiocarpal & radioulnar)
3.AO
4.Melone (impaction of lunate)
Gartland & Werley

1. Simple Colles fracture without intrarticular involvement

2. Comminuted Colles' fractures with intra-articular extension without displacement
3. Comminuted Colles' fractures with intra-articular extension with displacement
4. Extra-articular, undisplaced
Frykman Classification

Importance of sigmoid
notch articular
surface
Melone

Type I: Stable fracture without displacement. This pattern has characteristic fragments of the radial styloid and
a palmar and dorsal lunate facet.
Type II: Unstable “die punch” with displacement of the characteristic fragments and comminution of the
anterior and posterior cortices
– Type IIA: Reducible
– Type IIB: Irreducible (central impaction fracture)
Type III: “Spike” fracture. Unstable. Displacement of the articular surface and also of the proximal spike of the
radius
Type IV: “Split” fracture. Unstable medial complex that is severely comminuted with separation and or rotation
of the distal and palmar fragments
Type V: Explosion injury
AO/ OTA
Classification
 Options for
Treatment
Casting
– Long arm vs. short arm
External Fixation
– Joint-spanning
– Non bridging
Percutaneous pinning
Internal Fixation
– Dorsal plating
– Volar plating
– Combined dorsal/volar
plating
– focal (fracture
specific) plating
Indications for Closed
Treatment
Low-energy fracture
Low-demand patient
Medical co-morbidities
Minimal displacement- acceptable
alignment
 Closed Treatment of Distal
Radial Fractures
Obtaining and then maintaining an acceptable reduction

Acceptable reduction :

Immobilization:
– long arm (cast for high demand)
– short arm adequate for elderly patients

Frequent follow-up necessary in order to diagnose re-displacement.

Technique of Closed Reduction
Anesthesia (pain relief & decrease muscle spasm)
– Hematoma block
– Intravenous sedation
– Bier block
Traction: finger traps and weights
Reduction Maneuver (dorsally angulated fracture):
– hyperextension of the distal fragment,
– Correct radial tilt
– Maintain weighted traction and reduce the distal to the
proximal fragment with pressure applied to the distal radius.
Apply well-molded splint or cast, with wrist in neutral to
slight flexion.
Do check X-ray to confirm the acceptable reduction.
 After-treatment

Watch for median nerve symptoms

– parasthesias common but should diminish over few
hours
– If persist release pressure on cast, take wrist out of
flexion
– Acute carpal tunnel: symptoms
progress; CTR required
Follow-up x-rays needed in 1-2 weeks to evaluate
reduction.
Change to short-arm cast after 2-3 weeks, continue
until fracture healing.
 Prediction of Instability
1. Age > 80
2. Initial displacement of fracture (esp Radial shortening)
3. Extent of metaphyseal comminution
4. Displacement following closed reduction
 Management of
Redisplacement
• Repeat reduction and casting
– high rate of failure
• Repeat reduction and percutaneous
pinning
• External Fixation
• ORIF
Indications for Surgical
Treatment
1. High-energy injury with instability
2. Comminuted displaced intraarticular fracture
3. Open injury
4. Radial inclination < 15°
5. Articular step-off, or gap > 2mm
6. Dorsal tilt > 10 °
7. DRUJ incongruity
Operative Management of
Distal Radius
Fractures
 Treatment Options
• Type I
– Mostly non operative
– Few by external fixation
• Type II
– ORIF with buttress plate
• Type III
– Fixation with multiple K wires & plates with cancellous
bone grafting
– Open & closed techniques in combination
• Type IV
– Secure reduction of carpus to distal radius by K wires
• Type V
– Combination of percutaneous pinning & external fixation
 Percutaneous pinning
– Manipulate and reduce the fracture.
– Insert two large unthreaded Kirschner wires through the
radial styloid across the fracture and into the opposite
metaphyseal cortex
– Confirm good reduction and pin placement with
radiographs or image intensification; cut the pins off
beneath the skin.
– The arm is immobilized in a cast above the elbow with the
forearm and wrist in neutral position.
– K wires removed in 6 weeks and gentle range of motion
started.
Percutaneous Pinning-Methods
• most common radial styloid pinning + dorsal-
ulnar corner of radius pinning
•supplemental immobilization with cast, splint
in conjunction with external fixation
(Augmented external fixation)
Percutaneous
Pins
 Percutaneous Pinning
2 radial styloid pins
Crossed Pins
Percutaneous Pinning-
Kapandji
• intrafocal pinning through fracture site
• buttress against displacement
 Pins & plaster traction
– For severely comminuted distal radius fracture unsuitable
for K wire fixation and if commerical external fixator
not available.
– insert a 2.4-mm Steinmann pin transversely through the
proximal ulna 7.5 to 10 cm distal to the olecranon
– Insert a second pin transversely through the bases of the
second and third metacarpals.
– Apply a plaster cast to above the elbow, incorporating the
two pins in plaster.
– The pins and cast or fixator are left in place for 8 weeks.
 Distraction plate fixation
– Alternative to external fixation for highly comminuted
distal radius fracture.
– Distraction plate acts as an internal fixator.
– Advantages:
• External pin tract sites complication avoided.
• Secondary bone grafting procedures are done more easily in
absence of overlying external fixator.
 Barton Fracture
– Dorsal Barton Fracture : involves dorsal articular margin of
distal radius & subluxation/dislocation of carpus dorsally.
– Volar Barton Fracture: involves volar articular margin of distal
radius & subluxation/dislocation of carpus in volar.
– Closed reduction can be done for small marginal fracture but
redisplacement is common.
– Position of immobilization
• Dorsal Barton : Wrist dorsiflex, forearm pronated.
• Volar Barton : Wrist flex, forearm supinated.
– Volar marginal fracture Rx: Volar buttress plate fixation (Ellis
technique)
– Dorsal marginal fracture : Open reduction & fixation with K
wires/small screws. (Avoid plate & screw immediately under
the extensor tendons)
 Unstable intra articular distal
• radius fracture
The goal of operative treatment of unstable
intraarticular distal radial fractures is anatomical
reduction of the scaphoid facet, lunate facet, and
• sigmoid notch of the distal radioulnar joint.
Volar plating, interfragmentary Kirschner wires,
and external fixation all may be necessary for
•
stable fixation.
–
2 types of plates:
–
Conventional plate: In minimal comminution
Fixed angled plate : suitable for unstable, comminuted

» Periosteal blood supply is maintained

Internal Fixation of Distal
Radius Fractures
• elevation of depressed articular fragments
• required if articular fragments can not be
adequately reduced with percutaneous
methods
• Volar approaches most common
 Selection of
Approach
Based on location of fracture and displacement

Volar approach for volar rim fractures and

comminuted fractures that can be reduced
Dorsal approach
– Occasionally for dorsally displaced fractures that
can’t be reduced from volar approach
Combined approaches needed for high-energy
fractures with significant axial impaction.
DORSAL
 VOLAR
Classical Henry approach Extended carpal tunnel approach
Volar Plating for Dorsal Fractures

-less tendon irritation than dorsal plating

- indirect reduction

-better tolerated than Ex fix

 Fragment specific ORIF of
comminuted distal radius
fracture
• Combines both K-wire fixation & plate fixation which
enables secure fixation.
• Five potential fracture fragments are possible
– Radial column
– Dorsal cortical wall
– Intrarticular
– Dorsal Ulnar split
– Volar rim
• Trans styloid radial K wire has only single point of fixation
so it can’t prevent radial drift of distal fracture fragment.
• Pin-plate greatly enhances Kirschner wire fixation. In
addition, pin-plate adds buttress to radial column fragment.
 External fixation
• Method of choice for fractures with simple intra-
articular components and extensive
metaphyseal comminution.
• Type
–s Bridging : Crosses radiocarpal joint
– Non bridging: Doesn’t cross radiocarpal joint
 Spanning
•A spanning fixator is one which fixes
distal radius fractures by spanning
the carpus; I.e., fixation into radius
and metacarpals
•Bridging external fixation allows
distraction across the radiocarpal joint and
directly neutralizes axial load.
•Ligamentotaxis of the fracture fragments
•Adjunctive fixation and supplemental
bone grafting results in earlier union.
 Reduction Tactics
• Distraction as means of reducing distal
radius fractures
• Spanning fixator relies on distraction as
principle method of reducing fracture
fragments
• Distraction (Ligamentotaxis) excellent for
restoring length
 Ligamentous
Anatomy
Volar ligaments Dorsal ligaments
– Zigzag
– Straight fibers
– Elastic
– Stout
– Tighten slowly
– Tighten
readily
 VOLAR
LIG A M EN T S
MORE
STOUT

Dorsal
ligaments more
lax, zigzag
Pin Placement
 Non-
spanning
•A non-spanning fixator is one which fixes
distal radius fracture by securing pins in the
radius alone, proximal to and distal to the
fracture site.
•Indication : extra-articular or minimal intra-
articular dorsally displaced fractures with
metaphyseal instability
•Contraindication : lack of space for pins in the
distal fragment. 1 cm of intact volar cortex
required for purchase of pins
 Factors Affecting
Functional Outcome
McQueen (1996): carpal alignment after distal
radius fractures is the main influence on
final outcome
– malalignment has significant negative effect on
function
– failure to restore volar tilt predisposes to carpal
collapse and carpal malalignment
 Non-Spanning vs. Spanning
Fixator
McQueen, JBJS-B, 1998
Prospectively studied 30 spanning vs. 30 non-
spanning fixator patients
Non-spanning better preserved volar tilt, prevented
carpal malalignment, gave better grip strength and
hand function
Complication rate 50% lower
 Complications

Complication rates high

– Pin track infection
– RSD Finger stiffness
– Loss of reduction;
early vs. late
– Tendon rupture
Thank
You