Distal Radius Fractures - Trauma (2023)

• accounts for 17.5% of all fractures in adults

• more common in females (2-3:1)

• bimodal distribution

  • younger patients due to high energy mechanisms

  • older patients due to low energy mechanisms (i.e. FOOSH)

• 50% are intra-articular

• osteoporosis

  • high incidence of distal radius fractures in women > 50 years old

  • distal radius fractures are a predictor of subsequent fractures

    • DEXA scan is recommended for women with distal radius fractures

• mechanism of injury

  • fall on outstretched hand (FOOSH) is most common in older population

  • higher energy mechanism more common in younger patients

• DRUJ injuries

• radial styloid fractures

  • indicates higher energy mechanism

• soft tissue injuries -seen in 70%

  • TFCC injury (40%)

  • scapholunate ligament injury (30%)

  • lunotriquetral ligament injury (15%)

• responsible for 80% of axial load

• articulates with

  • scaphoid

    • via scaphoid fossa

  • lunate

    • via lunate fossa

  • distal ulna

    • via ulnar/sigmoid notch

• comprised of 3 columns

  • radial column

    • includes the radial styloid and scaphoid fossa

    • functions

      • attachment sites for the brachioradialis tendon, long radiolunate ligament, and radioscaphocapitate ligament

      • serves as a buttress to resist radial carpal translation

      • functions as a load-bearing platform for activities performed with the wrist in ulnar deviation

      • holds the carpus out to length radially, allowing a more uniform distribution of load across the scaphoid and lunate facets

      • serves as an anchor for the radioscaphocapitate ligament that prevents ulnar translation of the carpus

  • intermediate column

    • lunate fossa

    • functions

      • transmits load from the carpus to the forearm

  • ulnar column

    • includes the TFCC and distal ulna

    • functions

      • stability of the DRUJ

      • forearm motion

Fernandez

• based on mechanism of injury

Frykman

• based on joint involvement (radiocarpal and/or radioulnar) +/- ulnar styloid fracture

Melone

• divides intra-articular fractures into 4 types based on displacement

AO

• comprehensive but cumbersome

• usually a fall onto outstretched hand (FOOSH)

• wrist pain

• wrist swelling

• wrist deformity

• inspection

  • ecchymosis & swelling

  • diffuse tenderness

  • visible deformity if displaced

• motion

  • limited by pain

• recommended views

  • AP

  • lateral

  • oblique

• findings

• indications

  • evaluate intra-articular involvement

  • surgical planning

• indications

  • evaluate for soft tissue injury

    • TFCC injuries

    • scapholunate ligament injuries (DISI)

    • lunotriquetral injuries (VISI)

Nonoperative

• closed reduction and splint/cast immobilization

  • indications

    • extra-articular

    • < 5mm radial shortening

    • dorsal angulation < 5° or within 20° of contralateral distal radius

• CRPP

  • indications

    • extra-articular fracture with stable volar cortex

  • outcomes

    • 82-90% good results if used appropriately

• ORIF

  • indications

    • radiographic findings indicating instability (pre-reduction radiographs best predictor of stability)

    • dorsal angulation > 5° or > 20° of contralateral distal radius

    • volar or dorsal comminution

    • displaced intra-articular fractures > 2mm

    • radial shortening > 5mm

    • associated ulnar fracture

      • associated ulnar styloid fractures do not require fixation

    • severe osteoporosis

    • articular margin fractures (dorsal and volar Barton's fractures)

      • the volar ulnar corner (critical corner) supports the volar lunate facet with its strong radiolunate ligament attachments

      • failure to address this fragment can result in volar carpal subluxation

    • comminuted and displaced extra-articular fractures (Smith's fractures)

    • die-punch fractures

    • progressive loss of volar tilt and radial length following closed reduction and casting

• external fixation

  • indications

    • open fractures

    • highly comminuted fractures

    • medically unstable patients unable to undergo a lengthy procedure

  • outcomes

    • important adjunct with 80-90% good/excellent results

    • alone cannot reliably restore 10° palmar tilt

      • therefore usually combined with percutaneous pinning technique or plate fixation

• technique

  • reduction

    • requires adequate anesthesia

    • apply longitudinal traction and volar/dorsal pressure to the distal fracture fragment

  • immobilization

    • avoid positions of extreme flexion and ulnar deviation (Cotton-Loder Position)

      • due to risk of carpal tunnel syndrome

  • rehabilitation

    • no significant benefit of physical therapy over home exercises for simple distal radius fractures treated with cast immobilization

  • outcomes

    • repeat closed reductions have < 50% satisfactory results

    • LaFontaine predictors of instability

      • radial shortening is the most predictive of instability, followed by dorsal comminution

      • severe osteoporosis

      • associated ulnar fracture

      • dorsal comminution > 50%, palmar comminution, intraarticular comminution

      • dorsal angulation > 20°

      • initial displacement > 1cm

      • initial radial shortening > 5mm

    • higher loss of reduction with 3 or more of LaFontaine criteria

    • Meta-analyses and systematic reviews demonstrate no difference in functional outcomes between closed treatment versus operative methods in elderly patients (>65 years old)

  • complications specific to this treatment

    • acute carpal tunnel syndrome

    • EPL rupture

• technique

  • Kapandji intrafocal technique

    • K wires are placed dorsally into the fracture and used as reduction tools until they are driven into the proximal radius

  • Rayhack technique with arthroscopically assisted reduction

• complications specific to this treatment

  • radial sensory nerve injury

  • pin tract infections

• technique guides

  • distal radius extra-articular fracture ORIF with volar approach

  • distal radius intra-articular fracture ORIF with dorsal approach

• types

  • volar plating

    • preferred over dorsal plating

    • associated with irritation of both flexor and extensor tendons

      • rupture of FPL is most common with volar plates

        • associated with plate placement distal to watershed area, the most volar margin of the radius closest to the flexor tendons

    • can have hyperesthesia over the base of the thenar eminence due to palmar cutaneous nerve injury during retraction of the digital flexor tendons when plating the distal radius

    • new volar locking plates offer improved support to subchondral bone

  • dorsal plating

    • indicated for displaced intra-articular distal radius fractures with dorsal comminution

    • historically associated with extensor tendon irritation and rupture

• technique

  • can combine with external fixation and percutaneous pinning

  • perform bone grafting if complex and comminuted

  • study showed improved results with arthroscopically-assisted reduction

  • volar lunate facet fragments may require fragment-specific fixation to prevent early postoperative failure

• complications specific to this treatment

  • screw penetration into the radiocarpal joint or DRUJ

    • assess intra-articular screws with a 23 degree elevated lateral view

    • assess dorsal cortex penetration with a skyline view

  • tendon rupture

• outcomes

  • no benefit of therapist-directed physical therapy compared to home exercise program

• technique guides

  • distal radius fracture spanning external fixator

  • distal radius fracture non-spanning external fixator

• types

  • spanning ex-fix

    • useful for fractures with small articular fragment

  • non-spanning ex-fix

    • useful for fractures with large articular fragment

• technique

  • relies on ligamentotaxis to maintain reduction

  • place radial shaft pins under direct visualization to avoid injury to superficial radial nerve

  • avoid overdistraction (carpal distraction < 5mm in neutral position) and excessive volar flexion and ulnar deviation

  • limit duration to 8 weeks and perform aggressive OT to maintain digital ROM

• complications specific to this treatment

  • malunion

  • nonunion

  • stiffness and decreased grip strength

  • pin complications (infections, fractures through pin site, skin difficulties)

    • pin site care comprising daily showers and dry dressings recommended

  • neurologic (iatrogenic injury to radial sensory nerve, median neuropathy, RSD)

Median nerve neuropathy (CTS)

• incidence

  • most frequent neurologic complication

  • seen in 1-12% of low energy fxs and 30% of high energy fxs

• risk factors

  • prevent by avoiding immobilization in excessive wrist flexion and ulnar deviation (Cotton-Loder position)

• treatment

  • acute carpal tunnel release

    • indications

      • progressive paresthesias, weakness in thumb opposition

      • paresthesias that do not respond to reduction and last > 24-48 hours

• risk factors

  • DRUJ injury

EPL rupture

• risk factors

  • nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the EPL tendon

    • extensor mechanism is thought to impinge on the tendon following a nondisplaced fracture and causes either a mechanical attrition or a local area of ischemia in the tendon

  • volar plating with screw fixation that penetrates the dorsal cortex and is proud dorsally

• treatment

  • EIP to EPL transfer

FPL rupture

• risk factors

  • very distal volar plate placement on the radius (distal to watershed line) is associated with FPL rupture

    • due to physical contact of tendon on plate and subsequent tendinopathy

• incidence

  • 90% young adults will develop symptomatic arthrosis if articular stepoff > 1-2mm

• may also be nonsymptomatic

Malunion/nonunion

• intra-articular malunion

  • treatment

    • revision at > 6 weeks

• extra-articular angulation malunion

  • treatment

    • opening wedge osteotomy with ORIF and bone grafting

    • delayed procedure associated with higher need for bone grafting and a more difficult procedure

• radial shortening malunion

  • radial shortening associated with greatest loss of wrist function and degenerative changes in extra-articular fractures

  • treatment

    • ulnar shortening

• risk factors

  • DRUJ injury

• prevention

  • AAOS 2010 clinical practice guidelines recommend vitamin C supplementation to prevent incidence of RSD postoperatively

• worker's compensation

• low socioeconomic status

• low education levels

• low bone density

• accuracy of articular reduction

• restoration of anatomic relationships

• early efforts to regain motion of wrist and fingers