Distal end radius fracture

FRACTURE OF THE DISTAL
RADIUS
PRESENTER-Dr.SUNIL C P.G IN
ORTHOPAEDICS
MODERATOR-Dr.GUNNAIAH

INTRODUCTION
 Distal radius fracture represent approximately one sixth
of all fractures
 There are three main peaks of fracture
distribution,children aged 5-14 years,male aged under 50
years and females over the age of 40 years
 Distal radius fractures occur through the distal metaphysis
of the radius
 May involve articular surface
 frequently involving the ulnar styloid

predominantly male population who sustain athletic and
high-energy injuries and a second peak in the elderly,
predominantly female population characterized by lower-
energy or “fragility” fractures
Distal radius fractures tend to cluster in recognizable
patterns, and it is important that the treating physician be
familiar with the multiple fracture variants to recognize a
fracture's “personality,” that is, its behavioral
characteristics, energy of injury, relative stability,
associated soft tissue injuries, radioulnar involvement,
and prognosis

ANATOMY OF DISTAL RADIUS
• The epiphysis of the distal radius usually appears at one year
of age,it grows more in lateral than medial direction and
forms the radial styloid process,five facets and three articular
fossae(scaphoid,lunate,and sigmoid notch) distal radius fuses
with diaphysis at 17 years of age in females and 19 years in
male
• Five facets are named after their
position:distal,volar,dorsal,medial and lateral
• The distal articular facet is triangular in shape and covered
completely by hyaline cartilage and has 2 specific areas,the
scaphoid and lunate fossae,which articulate with proximal
carpal row by scaphoid and lunate bones respectively.

The metaphysis is flared distally in both the AP and the lateral
planes with thinner cortical bone lying dorsally and radially . The
significance of the thinness of these cortices is that the fractures
typically collapse dorsoradially. In addition, the bone with the
greatest trabecular density lies in the palmar ulnar cortex
In the anteroposterior plane the strongest bone is found under
the lunate facet of the radius. The line of force passes down the
long finger axis through the capitolunate articulation and
contacts the radius at this location. The “palmar ulnar corner” is
often referred to as the keystone of the radius. It serves as the
attachment for the palmar distal radioulnar ligaments and also
for the stout radiolunate ligament. Displacement of this
fragment is associated with palmar displacement of the carpus
and also with loss of forearm rotation

CONTINUE.....
• The anterior aspect of distal radius is smooth and
concave except at the insertion of the pronator
quadratus
• The posterior aspect of the distal radius is narrower
than the anterior aspect,the most prominent ‘V’
shaped crest is called lister’s tubercle.
• The medial aspect of distal radius is triangular and
presents an articular facet at its distal end which is
concave and is called sigmoid notch,it articulates
with the convex head of the distal ulna.The origin of
TFCC attaches to the distal border of sigmoid fossa.

Cross-sectional anatomy of the radial metaphysis.
Note that the dorsal surface is much more irregular
than the palmar surface. The V-shape dorsally
caused by Lister's tubercle (arrow) makes it difficult
to contour a plate to fit the dorsum of the radius.

continue
The lateral aspect of the distal radius is separated from
posterior by lister’s tubercle.A vertical groove forms
where APL and EPB excursion can be seen clearly

Ligamentous anatomy
• The extrinsic ligaments of the wrist play a major role in
the use of indirect reduction techniques. The palmar
extrinsic ligaments are attached to the distal radius, and
it is these ligaments that are relied on to reduce the
components of a fracture using closed methods. There
are two factors about these ligaments that make them
significant for reduction: First the orientation of the
extrinsic ligaments from the radial styloid is oblique
relative to the more vertical orientation of the ligaments
attached to the lunate facet.

CONTINUE
• The second significance of the ligamentous anatomy
is because of the relative strengths of the thicker
palmar ligaments when compared to the thinner
dorsal ligaments. In addition, the dorsal ligaments
are oriented in a relative “z” orientation, which
allows them to lengthen with less force than the
more vertically oriented palmar ligaments. The
significance is that distraction will result in the
palmar ligaments becoming taut before the dorsal
ligaments. Thus the palmar cortex is brought out to
length before the dorsal cortex. It is for this reason
that it is difficult to achieve reduction of the normal
12 degrees of palmar tilt using distraction alone

Applied anatomy
• Jakob and his co-authors interpreted the wrist as consisting of
three distinct columns, each of which is subjected to different
forces and thus must be addressed as discrete elements

The radial column, or lateral column
The radial column consists of the scaphoid
fossa and the radial styloid. Because of
the radial inclination of 22 degreees,
impaction of the scaphoid on the articular
surface results in a shear moment on the
radial styloid causing failure laterally at
the radial cortex. The radial column,
therefore, is best stabilized by buttressing
the lateral cortex

The intermediate column
The intermediate column consists of the
lunate fossa and the sigmoid notch of the
radius. The intermediate column may be
considered the cornerstone of the radius
because it is critical for both articular
congruity and distal radioulnar function.
Failure of the intermediate column occurs
as a result of impaction of the lunate on
the articular surface with dorsal
comminution. The column is stabilized by
a direct buttress of the dorsal ulnar aspect
of the radius

The medial column
The ulnar column consists of
the ulna styloid but also
should include the TFCC and
the ulnocarpal ligaments

Role of TFCC
• TFCC consists of articular disc,meniscus
homologue,dorsal and volar radioulnar
ligament,ulnocarpal ligament and ECU sheath
• TFCC is the main stabiliser of distal radioulnar joint in
addition to contributing to ulnocarpal stability
• TFCC normally not only stabilises the ulnar head in
sigmoid notch of radius but also acts as a buttress to
support proximal carpal row
• During axial loading the radius carries the majority of
load(82%),and the ulna a smaller load(18%)
• Increasing the ulnar variance to a positive 2.5mm
increases the load transmission across the TFCC to 42%
• The TFCC excised the radial load increases to 94%

Pathomechanism of distal radius
fracture
• The theory of compression impaction by dupuytren
in 1834
• The avulsion theory in 1852
• The incurvation theory by mayer in 1940
• 1983 Vidal et al conducted a cadaveric study to
determine whether ligamentotaxis restore radio
palmar tilt in 1A fracture of distal radius..

Pathomechanism of posteriorly
displaced fracture
• The usual cause is fall on the hyperextended wrist
• A)The theory of compression impaction when is
hyperextended proximal carpal bones come and impact dorsal
aspect of radius and body weight is transmitted through long
axis of radius to distal end and compression occur at dorsal
aspect of distal radius leading to fracture
• B)The avulsion theory-The indirect force presented by the
body weight are transmitted through humerus,ulna,radius
and then a volar wrist ligaments.Then fracture occured by
avulsion mechanism applied by the tensile forces transmitted
by the volar wrist ligaments.

CONTINUE....
• The Incurvation theory-depends on position of the hand,the
extent of the area of impact,the magnitude of the applied
force

Pathomechanism of anteriorly
displaced fracture
• A)Axial stress on the radius with a backward fall on
the palm of the hand.Wrist in extension and without
displacement of the body over the hand.The radius
incurved sustains compression force on the volar
cortex and tensile forces on the dorsum
• B)Forced flexion where direct compression stress on
volar cortex combined with traction exerted by the
dorsal ligament

Classification
• A)classification based on different fracture types
• 1)Colles fracture/pouteau’s fracture
• 2)Smith’s farcture/reverse colles fracture
• 3)Barton’s fracture
• 4)Chauffer’s fracture
• 5)Lunate load or die punch fracture

CONTINUE
• B)Universal classification
1)Extraarticular
2)Intraarticular
 C)Other types

Colles fracture
• It is an extraarticular fracture occurs at corticocancellous
junction of distal end of radius within 2cm from the articular
surface
• It may extend into DRUJ with six displacements
1. Impaction
2. Lateral displacement
3. Lateral rotation (angulation)
4. Dorsal displacement
5. Dorsal rotation (angulation)
6. Supination.
 It may often accompany fracture of the ulnar styloid which
signify avulsion of the TFCC and ulnar collateral ligaments

Smith’s fracture/Reverse colles
fracture
 Occurs at the same level on the distal radius as a colles' fracture.
 Distal fragment displaced in palmar (volar) direction with a "garden
spade" deformity.
• Modified Thomas Classification of Smith's Fracture:
• Type I: Extraarticular
• Type II:Crosses into the dorsal articular surface
• Type III:Enters the radiocarpal joint(equivalent to volar
barton fracture dislocation)

Smith's fracture (reverse colle's or volar
Barton's)
typical deformity: garden-spade deformity
1. Dorsal prominence of the distal end of the
proximal fragment
2. Fullness of the wrist on the volar side due to
the displaced distal fragment
3. Deviation of the hand toward the radial side

Barton’s fracture
• It is an intrarticular fracture dislocation or
subluxation in which the rim of the distal radius
dorsally or volarly is displaced with the hand and
carpus
• There are 2 types
Dorsal barton
volar barton

• . Dorsal Barton:
• Dorsal rim fracture of distal radius
• Mechanism:
• Fall with dorsiflexion and pronation of the distal
forearm on a flexed wrist.
2. Volar Barton:
Palmar rim fracture of distal radius
• Mechanism:
• It is due to palmar tensile stress and dorsal shear
stress and is usually combined with radial styloid
fracture.

Dorsal Barton fracture. Volar Barton fracture

Chauffeur’s fracture/hutchison
fracture
• It is an intraarticular fracture involving the radial
styloid,the radius is cleaved in a sagittal plane and
the fragment is displaced proximally.Isolated fracture
of the radial styloid are fairly common from
backfiring of starting handle of car

Lunate load/Die punch fracture
• It is an intraarticular fracture with
displacement of the medial articular surface
which usually represents a depression of
dorsal aspect of lunate fossa

Universal classification
• A)Extraarticular farcture
• Type 1-unstable and stable
• Type2-dispalced
a)Reducible and stable
b)reducible and unstable
c)irreducible
B)Intraarticular fracture
Type1-undisplaced and stable
Type 2-Displaced
a)Reducible and stable
b)Reducible and unstable
c)irreducible
d)complex

Other Classifications
1)Based on radiographic appearance or fracture
displacement direction
a.AO classification
b.serminto classification
c.lidstrom classification
2)Based on mechanism of injuries
a.Fernandez classification
b.casting classification
c.lischeid classification

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3)Based on articular joint surface involvement
a.Mayo classification
b.Jupitor classification
c.McMurthy classification
d.Melone classification
4)Based on degree of communition
a.Gartland and werley classification

(a) metaphyseal comminution;
(b) intra-articular extension; and
(c) displacement of the fragments.
Group I: Simple distal radius fracture with no involvement of
the radial articular surfaces
Group II: Comminuted distal radius fractures with intra-
articular extension without displacement
Group III: Comminuted distal radius fractures with intra-
articular extension with displacement
Group IV: Extra-articular, undisplaced
Gartland and Werley proposed a classification system
that assessed the three basic components of these
injuries

Frykman established a classification that incorporated
individual involvement of the radiocarpal and radioulnar
joints.
Type I: Extra-articular fracture
Type II: Extra-articular fracture with ulnar styloid fracture
Type III: Radiocarpal articular involvement
Type IV: Radiocarpal involvement with ulnar styloid fracture
Type V: Radioulnar involvement
Type VI: Radioulnar involvement with ulnar styloid fracture
Type VII: Radioulnar and radiocarpal involvement
Type VIII: Radioulnar and radiocarpal involvement with ulnar
styloid fracture

Frykman classification considers involvement of radiocarpal
& RU joint,
in addition to presnce or absence of frx of ulnar styloid
process;
classification does not include extent or direction of initial
displacement, dorsal comminution, or shortening of the
distal fragment;
hence, it is less useful in evaluating outcome of treatment;

such as Colles (dorsal angulation) or Smith (volar
angulation) fractures.
One cortex fails in tension, and the opposite
cortex is comminuted and impacted.
volar Barton, dorsal Barton and radial styloid
fractures.
extra-articular bending fractures of the
metaphysis
fractures are shearing fractures of the joint
surface
FERNANDEZ CLASSIFICATION
TYPE – 1
TYPE 2

Type 3
cause intraarticular fractures and impaction of
metaphyseal bone. These include complex
articular fractures.
compression fractures of the joint surface
with impaction of subchondral and
metaphyseal cancellous bone
avulsion fractures of ligament attachments,
includes dorsal rim and radial styloid fractures
associated with radiocarpal fracture-
dislocations.
TYPE 4

high-velocity injuries that involve
combinations of bending, compression,
shearing, and avulsion mechanisms or bone
loss
TYPE 5

Melone emphasized the effect of the impaction of the lunate on the
radial articular surface to create four characteristic fracture
fragments.
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 communition 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

The OTA/AO classification emphasizes the increasing
severity of the bony injury.
Type A: Extraarticular fracture. Subgroups are based on
direction of displacement and comminution.
Type B: Partial articular fracture. Subgroups are based on
lateral (radial styloid) palmar or dorsal fragments.
Type C: Complete articular. Subgroups are based on the
degree of comminution of the articular surface and the
metaphysis

CLINICAL FEATURES
A) SYMPTOMS
• History of a fall on the outstretched hand or an
episode of trauma
• A visible deformity of the wrist is usually noted, with
the hand most commonly displaced in the dorsal
direction.
• Movement of the hand and wrist are painful.
• Adequate and accurate assessment of the
neurovascular status of the hand is imperative,
before any treatment is carried out

• On Examination
Dorsal aspect of hand and wrist are usually swollen
and ecchymosed
The wrist should be examined for tenderness
Median nerve function and flexor and extensor
tendon action should be tested
Radial and ulnar styloids at same level(laugier sign)
Dinner fork deformity occurs in colles and dorsal
barton farcture
Gardenspade deformity occurs in smith or palmar
bartons fracture

CONTINUE
• associated fractures of either the radial head or
supracondylar humerus.
• An effort should also be made to identify an
ipsilateral scaphoid fracture, which may direct the
surgeon to consider operative versus nonoperative
management.
• attention should be directed to the extensor pollicis
longus, which may be injured acutely at Lister's
tubercle or may present with a late spontaneous
rupture.

MANAGEMENT
• X-ray picture of normal wrist:
• Styloid process of the radius extends I cm
beyond that of the ulna
• The articular surface of the radius projects
proximally and towards the ulna (average 23°)
- Radial angulation or inclination
• The plane of the radial articular surface slopes
downwards and forwards (average 11°).

The distal articular surface of the radius
Volar tilt/palmar tilt of 11 degress
Radial inclination of average 22 degrees
ie;inclination of distal radius towards the ulna
Radial length of 11-12 mm
Ulnar variance of 0-2 mm which indicates radial
shortening
Ulnar side of the wrist is supported by TFCC, which
articulates with both the lunate and triquetrum

1) Dorsal/Palmar Tilt
On a true lateral view a line is drawn connecting the most distal
points of the volar and dorsal lips of the radius. The dorsal or
palmar tilt is the angle created with a line drawn along the
longitudinal axis of the radius.
2) Radial Length
Radial length is measured on the PA radiograph. It is the distance
in millimeters between a line drawn perpendicular to the long
axis of the radius and tangential to the most distal point of the
ulnar head and a line drawn perpendicular to the long axis of the
radius and at the level of the tip of the radial styloid.
3) Ulnar Variance
This is a measure of radial shortening and should not be
confused with measurement of radial length. Ulnar variance is
the vertical distance between a line parallel to the medial corner
of the articular surface of the radius and a line parallel to the
most distal point of the articular surface of the ulnar head, both
of which are perpendicular to the long axis of the radius

4)Radial Inclination
On the PA view the radius inclines towards the ulna. This is
measured by the angle betwee a line drawn from the tip of the
radial styloid to the medial corner of the articular surface of the
radius and a line drawn perpendicular to the long axis of the
radius.
5)Carpal Malalignment
On a lateral view one line is drawn along the long axis of the
capitate and one down the long axis of the radius. If the carpus
is aligned, the lines will intersect within the carpus. If not, they
will intersect outwith the carpus

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• X-ray PA VIEW
• For extraarticular asses 1)radial shortening/communition
2)ulnar styloid fracture location
• For intraarticular asses 1)depression of the lunate facet 2)gap
b/n scaphoid and lunate facet 3)central impaction fragements
4)interruption of the proximal carpal row
• X-ray lateral view
For extraarticular fracture asses1)palmar tilt 2)extent of
metaphyseal communition 3)displacement of the volar cortex
4)scapholunate angle 5)position of the DRUJ

For intraarticular asses 1)depression of the palmar
lunate 2)depression of central fragement 3)the gap
b/n palmar and dorsal fragement
• Oblique view
1)For extraarticular asses radial communition
2)For intraarticular asses 1)the radial styloid for split
or depression2)depression of the dorsal lunate facet
 Tilted lateral view
It eliminates the shadow of radial styloid
And provide a clear tangential view of the lunate facet

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• CT scan:For conformation of occult fracture like
intraarticular fracture of lunate fossa
• MRI scan:For evaluation of suspected soft tissue
injuries
1. Flexor or extensor tendon injuries
2. Median nerve injuries
3. Early diagnosis of necrosis of sacphoid or lunate
4. Perforation of TFCC
5. Rupture of carpal ligaments

 Preserve hand and wrist function
 Realign normal osseous anatomy
 promote bony healing
 Avoid complications
 Allow early finger and elbow ROM
Goals of treatment

RATIONALE FOR TREATMENT
The goal of treatment of these fractures is a
wrist that provides sufficient pain-free motion
and stability to permit vocational and
avocational activities in all age groups without
the propensity for future degenerative changes
in the young

Palmar Tilt
Clinical studies have implicated the loss of the normal 11 degrees to 12 degrees
of palmar tilt as having a significant effect on functional outcome.The reason
for the loss of function is probably multifactorial. Short et al. found that as little
as a 10-degree loss of palmar tilt causes the area of maximum load on the
radius to become more concentrated and to shift dorsally. This change in load
concentration may explain the clinical findings relating dorsal tilt to
radiographically apparent degenerative changes at long-term follow-up.In
addition, the change in palmar tilt increases the tension on the palmar and
dorsal radioulnar ligaments, resulting in an increased load required for forearm
rotation
Radial Length/Ulnar Variance
Although collapse of the lunate facet results in radiocarpal incongruity,
collapse of the radial metaphysis results in radioulnar incongruity.Adams
found that positive ulnar variance resulted in the most significant changes in
the kinematics of the radioulnar joint when compared with loss of radial
inclination and palmar tilt because of loss of strength

Radial Inclination
Cadaver data indicate that the carpus shifts ulnarly in response to
loss of radial inclination, thereby resulting in increased load on
the triangular fibrocartilage complex (TFCC) and the ulna.
Carpal malalignment after distal radius fracture is usually an
adaptive process in response to dorsal or excessive palmar tilt
of the distal radius. The lunate tilts in the same direction as the
distal radius and the carpus adapts to this at the midcarpal joint
with flexion of the midcarpal joint in dorsal tilt and extension in
volar tilt in order to realign the hand on the forearm.
Carpal Malalignment

TREATMENT
Universal classification based treatment
TYPE TREATMENT
1)Non articular undisplaced Cast/splint
2)Non articular displaced Close reduction and cast application
Percutaneous pin fixation/external fixation
3)Articular undisplaced Cast/percutaneous pin fixation
4)Articular displaced
A)Reducible,stable
Cast/percutaneous fixation/external
fixation
B)Reducible,unstable
External fixation/ex fix with percutaneous
pin fixation
C)Irreducible
ORIF with plate
External fixation
Combined external and internal fixation

 Articular congruity (to reduce the wear of articular cartilage and
degenerative changes
 Radial alignment and length (to restore kinematics of the
carpus and radioulnar joint
 Motion (digits, wrist, and forearm to optimize return to functional
activities)
 Stability (to preserve length and alignment until healing of the
fracture
Principle goals of intervention

Stable Fractures
A fall on the outstretched hand may result in (1) a metaphyseal
bending fracture, (2) a lunate impaction fracture, or (3) an articular
shear fracture. The stability of the avulsion fractures is based on
the prognosis of the ligamentous injury, and combined injuries are
generally too unstable to be treated with cast immobilization.
A metaphyseal bending fracture that failed under tension must be
able to resist (a) axial load and (b) dorsal displacement
Lunate impaction fractures typically result secondary to axial
load.

Instability
• LeFontaine et al identified five factors indicative
of instability
1) Initial dorsal angulation of more than20 degrees
2) Dorsal metaphyseal communition
3) Intraarticular involvement
4) An associated ulnar fracture
5) Patient age older than 60 years

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• 2)Secondary instability-is present when closed reduction
and cast immobilisation fails to maintain the initial
reduction and there is residual dorsal angulation of 20
degrees and more and greater than 5mm of radial
shortening
• 3)Stable fracture are usually extraarticular with mild to
moderate displacement
• 4)Other factors influence operative interventions are
 a)open farcture
 b)associated carpal fracture
 c)associated neurovascular and impaired
contralateral extremity

Current trend in treatment of distal radius
fracture
• A)Conservative treatment with closed reduction and
cast application
• B)Surgical treatment
1. Percutaneous direct pinning
2. External fixation
3. External fixation and direct pinning
4. Bone grafting
5. Plate fixation
6. Wrist arthroscopy

A)Conservative treatment
• Stable fractures can be successfully treated with closed
reduction and immobilisation initially with a splint
followed by cast and weekly radiographic evaluation for
3 weeks
• Close reduction and cast application
A)Step 1-Disimpaction
B) step 2-Reduction
C)Step3-Locking the fracture by pronation
D)Application of plaster cast

Reduction of the distal metaphysis is reduced by increasing the
degree of the deformity and then applying longitudinal traction.
Only when sufficient traction has been applied can the distal
metaphyseal fragment be reduced on the shaft. The initial goal is to
reapproximate the palmar cortex. When the palmar cortex is re-
established then the cast has only to resist dorsal angulation Finally,
palmar tilt is restored using gentle pressure on the distal fragment.
In recalcitrant cases Agee's technique of palmar translation of the
hand relative to the forearm may be successful in restoring volar
tilt. Care is taken to avoid excessive palmar flexion of the
radiocarpal joint, which can result in an acute carpal tunnel
syndrome

A careful examination of the patient is performed with particular attention to (1) skin
quality and integrity, (2) median and ulnar nerve function as measured by 2-point
discrimination, and (3) continuity of the extrinsic digital flexor and extensor tendons, most
importantly those to the thumb.

Post reduction management
1. Take x-ray immedaitely after the application of the
cast.If reduction is not satisfactory,another attempt to
acheive accurate reduction should be made
2. If there is any circulatory embarrassment,split the cast
along the dorsum of its entire length
3. Elevate the arm with the fingers pointing towards the
ceiling for the first 48 hrs
4. Take x ray again on the 5th and 10th days ,check for
maintanance of position.
5. Institute physical therapy,heat,gentle massage,water
massage and active exercises for the
fingers,wrist,elbow and shoulder

continue
• Six pack exercises(codman type) is advised
1) Maximum extension of all digits
2) Opposition of the thumb
3) The grasp or fist exercise with all finger flexing to the
palmar creases or as near as possible to it
4) The claw exercise with the MCP joint of the fingers
kept extended but the IP joint maximally flexed
5) The table top exercise with the MCP joint maximally
flexed but the IP joint extended
6) Abduction and adduction af all digits
7) Plus use shoulder and elbow is a must

Comlications
• Failure or loss of reduction
• Skin complications
• Tendon adhesions and entrapement
• Carpal tunnel syndrome due to excessive palmar
flexion
• Nerve complications
• Vascular injury

1.Percutaneous direct pinning
• Aim of this procedure is to fix the mobile fragment to the
opposite cortex proximal to the fracture
• Direct pinning of the fragments especially the intermediate
column through the distal ulna add stability to the DRUJ
and medial half of articular surrface
• Application is extrafocal where entry point of k wire is away
from fracture site mainly 2 types a)transulnar b)transradial
• Indications-a)nonarticular displaced b)articular
nondisplaced c)articular displaced,all of which are reducible
and stable after reduction
• Contraindications are severebosteoporosis,severe
communition,soft tissue interruption and chauffer fracture

AFTERTREATMENT
The arm is immobilized in a cast above the elbow with
the forearm and wrist in neutral position. The Kirschner
wires that have been cut off just beneath the skin are
removed at 6 weeks. The wrist is supported with a
removable ball-peen splint, and gradual range-of-motion
exercises are permitted

2.Kapandji technique
intrafocal pinning with arum pins for nonarticular
fracture
• In intrafocal pinning a smooth k-wire is inserted after a
manual reduction,through a short skin incision,directly
into the fracture line
• Secondary displacement is made impossible by
immediate contact of the distal fragment with the arum
nut of the pins which are working as an abutement,not
as a resistant component

Kapandji technique of “double
intrafocal wire fixation” to reduce
and maintain distal radial
fractures. A 0.045- or 0.0625-inch
Kirschner wire is introduced into
the fracture in a radial to ulnar
direction. When the wire reaches
the ulnar cortex of the radius, it is
used to elevate the radial
fragment and recreate the radial
inclination. This wire is then
introduced into the proximal
ulnar cortex of the radius for
stability. A second wire is
introduced at 90 degrees to the
first in a similar manner to restore
and maintain volar tilt.

3.External fixation
• Three types of external fixation
1) Spanning external fixation
2) Nonspanning external fixation
3) Hybrid external fixation

Bridging/spanning ex-fix
• Bridging external fixation allows distraction across the radiocarpal
joint and directly neutralizes axial load.
• Initially external fixation was felt to provide “ligamentotaxis” to
the fracture fragments. The philosophy was that the intact wrist
capsule and ligamentous structures would “indirectly” reduce
both the metaphyseal displacement and any impacted articular
fragments, and open reduction would not be necessary
• Several detailed studies have documented that external fixation
alone may not be sufficiently rigid to prevent some degree of
collapse and some loss of palmar tilt during the course of
healing,so several adjunctives were used.

• Factors that mitigates against adequate reduction
include dorsal communition palmar soft tissue
interposition.A tendency of dorsal tilt and
displacement due to volar taut ligaments
• The external fixator which consists of
1) 3.5mm schantz pins for the radius 2 in number
2) 2.5mm schantz pins for the metacarpal 2 in number
3) Universal clamps
4) 4mm connecting rods

Adjunctive fixation
• Supplemental Graft
Supplemental bone graft or a bone graft substitute within the
fracture site has been used to fill the fracture gap.
Both bone inductive and conductive, which have been proposed
to fill the metaphysis and prevent fracture collapse.
• K-wire fixation
The use of adjunctive percutaneous pins has also been
introduced to improve the stability of external fixation and
prevent loss of reduction.
The use of crossed wires engaging the contralateral cortex
substantially further increases the rigidity of the construct.
The major complication seen with the use of pins is with
iatrogenic injury to the superficial radial nerve.

Both bone inductive and conductive, which have been
proposed to fill the metaphysis and prevent fracture
collapse.percutaneous introduction of a calciumphosphate
bone cement to treatment with external fixation or cast
application. The radiographic results demonstrated
superior maintenance of radial length in the cement
group.

Nonbridging external fixation
• Indications-Extra-articular or minimal intra-articular
dorsally displaced fractures with metaphyseal instability.
• The technique is not suitable for the treatment of volar
displaced fractures
• The main contraindication for the technique of
nonbridging external fixation is lack of space for pins in
the distal fragment: approximately 1cm of intact volar
cortex is required to give purchase for the pins.

•The main radiological advantage of nonbridging external
fixation is therefore restoration and maintenance of the
normal volar tilt of the distal radius. In bridging external
fixation, reduction
of the fracture depends on ligamentotaxis. Volar tilt may
not be restored, because the volar ligaments are shorter
and stronger than the dorsal ligaments and prevent full
reduction. With nonbridging external fixation the
reduction is performed using the distal pins as a joystick,
allowing the surgeon direct control of the distal fragment
and obviating the need for ligamentotaxis.

Combined Open Reduction and Internal Fixation with
External Fixation
This technique has been demonstrated to be effective when the
articular fragments are felt to be too small and too numerous for
internal fixation with plate-screw constructs, and yet the fracture
does not reduce anatomically with standard techniques. It has been
used primarily for high-energy injuries with comminution both
dorsally and palmarly. The technique permits internal fixation of the
comminuted fragments palmarly, and the use of the external fixation
device prevents collapse on the side opposite the plate
The technique is most often used when external fixation has been
performed and persistent incongruity of the palmar lunate facet is
demonstrated. It is critical to reduce and stabilize this facet to
obtain both articular congruity and distal radioulnar joint stability.

Complications of external fixation
• Overdistraction- Overdistraction of the wrist, particularly if it is
combined with palmar flexion, results in relative lengthening of
the extrinsic extensor tendons and may prevent full active and
passive digital motion. Prolonged loss of full flexion combined
with the swelling following a wrist fracture can result in
permanent loss of metacarpophalangeal motion.
• Cutaneous Nerve Injury- Injury to the superficial radial nerve
may be seen following open pin insertion, percutaneous half pin
insertion, or with the use of supplemental K-wires.
• Pin Tract Infections- For K-wires the incidence ranges from 6%
to as high as 33%. For external fixation pins the incidence has
been reported to range from 1% to 8%

Open Reduction and Internal Fixation
Open reduction of articular fractures of the distal radius
is indicated in active patients with good bone quality
when anatomic restoration of the joint surface cannot
be achieved by closed manipulation, ligamentotaxis, or
percutaneous reduction maneuvers or as an alternative
to percutaneous fixation at the preference of the
patient or surgeon.

 Articular fractures in elderly,
 inactive patients
 in those with massive osteoporosis
there is a risk for complications, including failure of fixation, nonunion, and
reflex sympathetic dystrophy
CONTRAINDICATIONS
However, since the recent introduction of “fixed-angle” internal fixation
devices, both unstable extra-articular and simple articular fractures in
elderly, active osteoporotic patients have increasingly satisfactory
outcomes with ORIF.
Subchondral buttressing with fixed-angle pins or screws secured to the
plate greatly reduce the incidence of settling or secondary articular
displacement

 surgical approach depends on the location and direction
of displacement of the fracture fragments. Thus, dorsally
or radially displaced fractures have been classically
approached through dorsal incisions, whereas volarly
displaced fractures (Smith's and reversed Barton's) are
classically approached through palmar exposures.
 There has been increased interest in the Mx of dorsally
displaced nonarticular and articular fractures with volar
fixed-angle plate fixation to decrease the incidence of
extensor tendon irritation associated with dorsally
applied implants.
 Palmar incisions are also appropriate for primary repair
of a torn wrist capsule in radiocarpal fracture-dislocations
and whenever primary median nerve decompression or
fasciotomy of the flexor compartment is indicated.

Dorsal plating
• Internal fixation using a dorsal plate has several
theoretical advantages. Technically familiar to most
surgeons, the approach avoids the neurovascular
structures on the palmar side. Further, the fixation is on
the compression side of most distal radius fractures and
provides a buttress against collapse. Initial reports of
the technique demonstrated successful outcomes with
the theoretical advantages of earlier return of function
and better restoration of radial anatomy than was seen
with external fixation.

•There were increasing reports of extensor tendon ruptures
because of prominent hardware, particularly at Lister tubercle. The
more distally the plate is applied on the dorsum of the wrist, the
more proximally the distal screws need to be directed to avoid
articular penetration. This oblique orientation of the screws allows
the distal fragment to displace palmarly. The palmar displacement
of the fragment is particularly problematic because it results in (1)
incongruity at the distal radioulnar joint and (2) prominence of the
hardware dorsally with the tendency for extensor tenosynovitis or
tendon rupture

Operative Technique
A longitudinal incision is centered over the fracture in line with the
ulnar aspect of Lister tubercle. The extensor retinaculum is incised in
a z-plasty manner that allows for one limb to be placed over the
plate and the second limb to be repaired over the extensor tendons
to prevent bow-stringing of the tendons with wrist extension. The
extensor pollicis longus tendon is dislocated from its position at the
tubercle and subperiosteal dissection is performed radially and
ulnarly. Care should be taken to preserve all of the dorsal fragments
for re-establishment of radial length. Traction is then applied by
either an assistant or by the use of finger traps with weights
suspended off the end of the table. Care should be taken to ensure
that the hand is not pronated relative to the forearm.

Dorsal Plate Fixation
including irritation,
synovitis,
attrition,
and tendon rupture because of direct contact of these
structures with the dorsal plates
complications,

Volar Plate Fixation
Regardless of the displacement of the distal
fragment (dorsal, volar, radial), volar plating of both
articular and nonarticular fractures is an effective
fixation method that may reduce some of the soft
tissue complications associated with dorsal plating.
Advantages of palmar exposure and volar plating
include the following

Minimal volar comminution facilitates reduction of dorsally
displaced fractures.
Anatomic reduction of the volar cortex facilitates restoration of
radial length, inclination, and volar tilt.
Avoidance of additional dorsal dissection helps preserve the
vascular supply of comminuted dorsal fragments
Because the volar compartment of the wrist has a greater cross-
sectional space and the implant is separated from the flexor
tendons by the pronator quadratus, the incidence of flexor
tendon complications is lessened.
The use of fixed-angle volar plate designs avoids screw “toggling”
in the distal fragment and thus reduces the danger of secondary
displacement
When stabilized with a fixed-angle internal fixation device that
uses subchondral pegs or screws, control of shortening and late
displacement of articular fragments are improved and the need
for bone grafting reduced
ADVANTAGES

Complications
• Locking plates is the potential for articular penetration
with distal plate position on the palmar surface of the
radius
• Collapse of the fracture also can lead to joint
penetration by the distal screws especially in osteopenic
patients
• Extensor tendon problems can be caused by penetration

Operative technique
• Palmar plates may be applied through either a flexor carpi radialis
(FCR)/radial artery interval or through a midline flexor
tendon/ulnar neurovascular bundle interval. The FCR/radial
artery approach is preferable for (1) fixation of dorsally displaced
fractures with dorsal comminution and (2) fixation of partial
articular fractures (articular shear fractures). The skin incision is
centered over the FCR, with care being taken to avoid injury to
the palmar cutaneous branch of the median nerve that lies ulnar
to the tendon. The radial artery is mobilized, and dissection is
carried radially by releasing the brachioradialis tendon from the
radial styloid.

The second surgical approach to the palmar radius is the flexor
tendon/ulnar neurovascular bundle interval. The skin incision is
centered over the ulnar border of the palmaris longus, the flexor
tendons are mobilized radially, and the ulnar neurovascular
bundle is taken ulnarly. With this approach the pronator
quadratus is released from the ulna. The incision may be
extended distally to release the transverse carpal ligament,
particularly if the patient had any median nerve symptoms
preoperatively. This incision is preferred when the majority of the
comminution is at the palmar lunate facet.

Associated injuries
1) Radial Styloid Fractures
Depressed radial styloid fractures are associated with a
high incidence of scapholunate ligament injuries in
younger patients
2) Volar Lip Injuries
3) Dorsal Lip Injuries
4) Ulnar Styloid Fractures
5) Interosseous Ligament Injuries
6) Triangular Fibrocartilage
(TFCC) Injuries

Complications
1) Chronic Regional Pain Syndrome
2) Nonunion
• Nonunion of distal radius fractures is rare but presents
unique treatment challenges because of the associated
pain, joint contractures, tendon imbalance or rupture, and
occasional severe bony deformity
• nonunion of ulnar styloid process fractures in conjunction
with distal radius fractures is quite common and yet is
rarely symptomatic
• Treatment of distal radius nonunion must be individualized
and based on the patient's symptoms, functional deficit,
and bony substance

 Malunion :
Malunion of the radius results in alterations to (1) the radiocarpal joint, (2) the
midcarpal joint, and (3) the radioulnar joint.
Recognition of associated carpal malalignment and DRUJ derangement is
mandatory to decide whether additional procedures together with radial
osteotomy are necessary to help ensure a good result
Assessment of carpal malalignment with malunited Colles’ fractures includes
determination of the presence of
(1) dorsal subluxation of the carpus,
(2) a type I (adaptive) dorsal intercalated segment instability (DISI) that is
reducible by radial osteotomy, or
(3) type II or fixed DISI pattern that does not improve after radial osteotomy
The typical deformity of the distal radius malunion has three components: (1) loss of
radial inclination, (2) loss of palmar tilt, and (3) pronation of the fracture fragment. The
surgical technique is dependent on the location of and the degree of the deformity

Dorsal Displacement with Loss of Radial Inclination
The osteotomy is best performed at the site of the deformity. Typically an opening
wedge osteotomy is performed and a corticocancellous graft is placed. Stabilization of
the osteotomy has been described using K-wires, dorsal plates, palmar plates, and
external fixators.
Palmar Displacement of the Distal Fragment
Palmar displacement (apex volar angulation) is best approached via a palmar
approach
If radial inclination has been lost then the FCR/radial artery approach allows
opening of the radial column and release of the contracted brachioradialis tendon.
Neurologic Injuries
Median Nerve
Ulnar nerve

Sudek’s dystrophy
tendon rupture,
 ulnar impaction,
 loss of rotation,
 finger stiffness, and
rarely, compartment syndrome.

Distal end radius fracture

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Distal end radius fracture