Fracture of Distal Radius

Anatomy

On the volar surface of the radius (see the image below), the luate facet it
to the left and the scaphoid facet is to the right. The projection of bone just
proximal and volar to the lunate facet is the lunate facet buttress. This is relevant
because it is what supports the lunate facet, and it must be stabilized in volarly
unstable fractures. The volar radial tuberosity is at the right margin of the bone, at
the radial margin of the watershed line. The surface is covered with the pronator
quadratus (PQ). The cortical bone is quite thick and is strong, even in osteoporotic
patients.

On the dorsal surface of the radius the Lister tubercle is seen in the center. This
bone is a thin cortical shell, with little structural strength.The ulnar surface of the
radius, with the sigmoid notch for articulating with the ulna, is shown in the image
below.

On the distal articular surface of the radius (see the image below), the
scaphoid facet is to the right, and the lunate facet is to the left. This bone is the
strongest of all the surfaces, and even if it is osteoporotic, it is quite strong.

Pathophysiology

The pathophysiology of a fracture is rather obvious: more load is imparted

to the bone than the bone can sustain. Osteoporotic bone can break with very low
impact. However, the patient should always be questioned regarding the
circumstances of the injury, especially if he or she is older. Heart attacks or
transient ischemic attacks can cause a DRF and should not be overlooked.

In addition, more problems may be involved with the injury besides the fracture
itself. Although it is typical to think of the injury as involving only a broken bone,
it is also worthwhile to consider that a DRF is a soft-tissue injury surrounding the
broken bone; the immediacy of the radiographic diagnosis should not distract the
surgeon from carefully assessing systemic issues or forearm soft-tissue issues.
Etiology

The standard DRF occurs in older patients, who have much weaker bones
and can sustain a DRF from simply falling on an outstretched hand in a ground-
level fall. An increasing awareness of osteoporosis has led to these injuries being
termed fragility fractures, the implication being that a workup for osteoporosis
should be a standard part of treatment. As the population lives longer, the
frequency of this type of fracture will increase.

Younger patients have stronger bone, and thus, more energy is required to
create a fracture in these individuals. Motorcycle accidents, falls from a height,
and similar situations are causes of high-energy DRFs, and such fractures must
considered to be a separate entity from the fractures in the older population. The
injury to bone and soft tissue in high-energy DRFs is greater than that in typical
DRFs. Trauma is the leading cause of death in the 15- to 24-year-old age group,
and this is also reflected in the incidence of lesser traumas such as DRFs.

History and Physical Examination

In a patient with a distal radius fracture (DRF), the history should be

directed toward ascertaining the probable amount of energy involved. A fall from
20 ft (~6 m) can be associated with a larger and more complex constellation of
injuries (ie, beyond the distal fracture seen on the radiograph) than would be seen
with a fall from a standing position. A history of prior fractures should be sought.
A history of fragility fractures helps predict the stability of any reduction. A
history of multiple high-energy fractures in a younger patient helps predict the
patient's ability to comply with directions.

The median nerve is always compressed by a fall on the palmar aspect of

the hand that results in a DRF, and the chart note should specifically document the
quality (not just the presence or absence) of median nerve function. This should
be documented at each visit for the first several weeks or months,

Most therapies for DRF have implications for the median nerve. A cast or
splint without a reduction may result in median nerve compromise due to
pressure. A reduction, whether closed or open, involves some level of anesthesia,
temporarily compromising the ability to assess the median nerve. Careful
documentation of median nerve function at the first assessment is critical to
planning and assessing treatment, not to mention protecting the surgeon from
subsequent claims. DRFs are overrepresented in orthopedic malpractice suits.

Classification

The goals of any classification system are as follows:

 To stratify the injuries

 To guide treatment

 To facilitate discussion

 To predict outcome

Each classification system has its merits and weaknesses with respect to each
goal, and often, more than one classification system is needed.

The classification systems used most frequently for DRFs are the Frykman,
Melone, AO (Arbeitsgemeinschaft für Osteosynthesefragen [Association for the
Study of Osteosynthesis]), and Fernandez systems. Their key characteristics are as
follows:

 The Frykman classification highlights the injury to the distal radioulnar

joint (DRUJ)

 The Melone classification, based on the paper by Scheck, highlights the

fragmentation of the articular surface, especially the dorsoulnar corner of
the distal radius

 The AO classification emphasizes the location as extra-articular, partial

articular, or completely articular

 The Fernandez classification is based on the mechanism of injury, deduced

from the displacement of the bone and the location of the fracture lines
A classification system that approaches the topic from another angle categorizes
fracture patterns according to the three-column concept of the wrist and proposes
treatment accordingly. This approach was independently developed by Medoff in
1994 (personal communication) and by Rikli and Rigazzoni. [5] The three columns
are as follows:

 Lateral column (the radial half of the radius, including the radial styloid
and the scaphoid facet, though Medoff differentiates these two)

 Central column (the ulnar half of the radius, including the lunate facet)

 Medial column (the ulna, the triangular fibrocartilage [TFC], and the
DRUJ)

Each column is considered separately as to its need for reduction and stabilization.
It should be noted that this conceptual approach does not exclude any other
approaches but, rather, is complementary to them.

Diagnosis

Imaging Studies

 Plain radiography

Plain radiographs (see the image below) are the foundation of treatment
and are all that is needed for most distal radius fractures (DRFs). If the DRF is
placed in traction as an early part of treatment, traction radiographs are very
helpful. Often, the fragments cannot be adequately identified or assessed on the
injury films; the traction views are often the first radiographs that define the
fragments. Final reduction films must be evaluated for adequacy of reduction and
for an assessment of stability, even though this is an area with no clear guidelines.

Posteroanterior radiograph demonstrating typical features of common distal

radius fracture: loss of radial length, loss of radial tilt, and comminution at
fracture line.

 Computed tomography
 Many consider computed tomography (CT) to be useful for evaluating the
articular fracture lines in an intra-artiocular fracture, particularly one that is
comminuted, and it is sometimes helpful for planning the approach. However,
others have felt that CT adds expense and delay but rarely changes the
intraoperative gameplan. Experience here is necessary, in that there are no clear
guidelines or criteria for when to obtain a CT scan.

It should be kept in mind that whereas plain films underestimate the number
of fracture lines, CT overestimates the number. CT is necessary in planning intra-
articular osteotomies for nascent malunions and mature malunions. Three-
dimensional (3D) reconstructions may look impressive in presentations, but to
date, they have not been very helpful in preoperative planning or postoperative
assessment.

One study examined whether the locations of DRFs correlate with the areas of
attachment of the wrist ligaments. [6] Using data from CT scans of acute intra-
articular DRFs, the study noted that articular DRFs were statistically more likely
to occur at the intervals between the ligament attachments than at the ligament
attachments. The most common fracture sites were the center of the sigmoid
notch, the area between the short and long radiolunate ligaments, and the central
and ulnar aspects of the scaphoid fossa dorsally.

These results suggest that CT may be used to identify the subsequent

propagation of the fracture and the likely site of the impaction of the carpus on the
distal radius articular surface. [6] This is a very interesting approach that will likely
become a standard part of understanding DRFs in the future, especially if the
method can be refined.

The threshold for treatment, though not clearly defined, often involves
assessing the degree of displacement (measured in millimeters). Both plain films
and CT scans have been evaluated for their accuracy at the 1-mm level. Neither
modality can reliably be read at this level, which adds to the challenge of treating
DRFs.
Treatment

No consensus has been reached on classification systems, indications for

surgery, or a particular choice of surgery (see below) since the orthopedic
community first rejected Colles' contention that all distal radius fractures (DRFs)
heal well. Gartland and Werley are generally credited with starting the revolution
in 1951 with their paper examining more than 1000 DRFs, and Jupiter brought the
discussion into the modern era with his 1986 paper in the Journal of Bone and
Joint Surgery that emphasized the importance of reduction.

Despite the large number of papers published each year on DRFs, no

consensus has been reached on treatment, and there is nothing in the literature to
suggest that a consensus might be developing. Indeed, with one approach
advocating immediate motion using a fixed-angle volar plate and another
advocating immobilization for 3 months using an internal joint-spanning plate,
treatment options seem to be diverging rather than converging.

One area of agreement is that DRFs in active adults should be reduced

anatomically. Unfortunately, however, no consensus has yet been reached on
precisely what "anatomically" means in this context. That is, is a 0.5-mm
displacement of an intra-articular fragment "anatomic"? What if it is extra-
articular? Is the same definition of "anatomic" appropriate both for young, active
patients and for older, inactive patients?

Even with classification no consensus has been reached. The International

Federation of Societies for Surgery of the Hand formed a working group of the
most distinguished minds in DRF management to investigate for the existence of a
consensus on the best classification system or, if one did not exist, to develop one.
This working group concluded that no available system was universally useful or
accepted and that the group could not develop a system that would be.

There is, however, a consensus that the goal of treatment is to restore the
patient to the prior level of functioning. This is the starting point for all
discussion.
  Indications for reduction or operative treatment

Most authors advocate an anatomic reduction. This admonition, however, has

two problems. First, not all patients need an anatomic reduction to be able to
resume their normal activities. Second, the concept of anatomic reduction is not
defined, as noted above. No authorities advocate operative reduction if the stepoff
is 0.5 mm; however, a stepoff of 0.5 mm is obviously not anatomic. On the other
hand, a 20° dorsal tilt is not anatomic, yet inactive elderly adults can easily return
to their previous level of functioning with this alignment.

The indications for reduction or operative treatment are not based solely on
age but must be tailored to the individual patient. It is also important, however,
not to err in the opposite direction—that is, by considering that any patient who is
"old" does not require an anatomic reduction (one paper defined "old" as 50 years
old!). Balanced judgment is required.

Most authors would recommend anatomic reduction in a patient who is active

in recreation (remembering that golf and tennis are common activities for persons
older than 70 years) or engages in forceful activities at work. Conversely, if the
patient is sedentary, a lesser reduction may allow return to full activities. Usually,
three parameters are relevant:

 Intra-articular stepoff - Most authors would accept less than 1 mm of intra-

articular stepoff but not more than 2 mm

 Dorsal tilt - Most authors would accept neutral dorsal tilt but not more
than 10° (the range is quite large in the literature, with some authors not
accepting more than neutral)

 Radial length - There is literature that suggests accepting 2 mm of radial

shortening but not more than 5 mm; however, most surgeons would not
accept more than 3 or 4 mm
Radial tilt is generally considered a lesser parameter.

Defining anatomic reduction in terms of intra-articular stepoff is

challenging. The main challenge lies in making a reliable determination of the
relevant parameters—that is, how to distinguish between less than 1 mm and
greater than 1 mm. The difficulty is that opinions are based on studies using
routine plain radiographs, which cannot accurately measure stepoffs with an
accuracy of 1 mm.

The threshold of 1 mm for intra-articular displacement is commonly cited,

referencing a 1986 landmark paper by Knirk and Jupiter. [7] However, Jupiter has
repeatedly stated that this threshold is not the benchmark that subsequent authors
have used, that the 1986 study had methodologic flaws, and that ligamentous
injuries may account for functional limitations better than intra-articular stepoff
does. Surgeons must review the literature with this in mind, because it changes the
reliability of the conclusions reached by many authors after 1986.

Fewer comparative studies (either basic science or clinical) have been

published on dorsal tilt, but this has not kept authors from making
pronouncements. The range of anatomic alignment for dorsal tilt has reportedly
been from 0° to 10°, with no proviso for less active patients. Given that a neutral
(0°) alignment represents an 11° loss of volar angulation, even the most
conservative figure is not truly anatomic.

Commonly, some older, inactive patients are able to achieve full

resumption of their activities with dorsal tilts of 45° or more. Although orthopedic
surgeons may find the radiographs of these patients disturbing and the clinical
deformity not much better, some patients are quite satisfied and able to function in
all of their activities of daily living (ADLs). This calls into question any rigid
threshold of dorsal tilt, whether it be 0° or 10°. Most authors recommend no more
than 0-10° of dorsal tilt in healthy, active individuals.

The basic science of radial length is clear. Shortening radial length by 2

mm doubles the load through the triangular fibrocartilage (TFC) and the ulna. The
clinical relevance of this fact in the context of DRFs is unclear. Additionally,
altering the radius length relative to the ulna affects the function and forces
associated with the distal radioulnar joint (DRUJ). On the basis of less well-
defined clinical grounds, most authors would not accept more than 3-4 mm of
shortening.

Stability of reduction

Another issue that has not been resolved is the stability of the reduction if
it is performed in a closed procedure and without operative support to the fracture
fragments. Some authors believe that a 30° dorsal tilt or any radial shortening will
not be stable and will subside; others feel that 20º is the correct threshold for
intervention. If function requires that reduction be achieved and maintained,
surgery is needed to maintain it.

Agreement has been reached that weekly radiographic assessment is

required for approximately 3 weeks for displaced fractures that have been
reduced. Fractures do not commonly subside after 3 weeks, but this is not a
certainty. Care must be taken to compare the current radiograph with the first
postreduction radiograph because subsidence is gradual and can be difficult to
detect between any two consective films.

Choice of treatment approach

Management of DRFs has always been an area of intense research and

innovation. It has changed more rapidly in the years since 2001 than in any
comparable previous period and has now stabilized. Whereas percutaneous
pinning and external fixation remain the mainstays of treatment throughout much
of the world, with strong and somewhat idiosyncratic national trends attributable
to the prominence of individual surgeons in those countries, volar fixed-angle
plating has become popular and has dramatically shifted the landscape in several
ways. [8, 9]

For many surgeons, the volar approach using fixed-angle devices designed
for subchondral support (in distinction to the bicortical approach of diaphyseal
plating), is the main treatment option for dorsally unstable DRFs. Orbay has
popularized this treatment and broadened its applicability to highly comminuted
intra-articular fractures with the extended flexor carpi radialis (FCR) approach,
pronating the radial shaft out of the way and looking directly at the undersurface
of the articular bone.

The low rates of complications and postoperative pain, the quality of the
results, and the rapid return to activities have, for some surgeons, shifted the
balance of risks to benefits in such a manner that they are offering patients the
option of surgery versus a cast for stable undisplaced or stable reducible fractures.

The complication rate for volar fixed-angle plates has not yet been clearly
defined. Most cases of tendon injury or rupture seem to be due to failure to follow
proper technique. One important aspect of technique is to avoid any past-pointing
of distal screws and, preferably, to place their tips 2-4 mm short of the dorsal
cortex. A second is to use a plate that does not extend distally as far as the volar
wrist capsule. Another landmark commonly used is the watershed line (see the
image below); plates should not extend proximal to or volar to this line.

Finally, many surgeons feel the tendons are better protected if the plate is
completely and securely covered with the pronator quadratus (PQ). Orbay and
Nelson have taught an approach known as the PQ technique, in which the PQ is
released with a rim of fibrous tissue cut from its origin along the lateral septum
and the proximal aspect of the volar wrist capsule. The rim of fibrous tissue along
the radial and distal aspects of the PQ that is left by this technique allows more
secure replacement of the muscle at the end of the procedure.

Arthroscopy continues to be a controversial adjunct to the management of

intra-articular fractures. Whereas the rate of unrecognized scapholunate,
lunotriquetral, and triangular fibrocartilage tears in DRF has been shown to be
greater than 60%, the role of arthroscopy continues to be controversial because of
a lack of any outcome studies that have demonstrated improved results
Nonoperative Therapy

In the treatment of DRFs, the goal is to return the patient to his or her prior
level of functioning. The physician's role is to discuss the options with the patient,
and the patient's role is to choose the option that best serves his or her needs and
wishes. This treatment paradigm can be illustrated by a case discussion of an
approach to the surgical treatment of stable fractures that are in acceptable
alignment.

Many DRFs can be treated nonoperatively. [12, 13] Those that are undisplaced
or minimally displaced (the definition of minimally displaced is controversial and
varies with age and activity level) can be treated in a cast for 6 weeks. In most
instances, unless the distal ulna is fractured and unstable (type I and II ulna
fractures are usually stable), it can be treated in a short arm cast. Long arm casts
are not required if the ulna is stable; additionally, these casts significantly disable
the patient during the treatment of the fracture. [14]

Some fractures in elderly persons that are compressed dorsally can be

minimally painful and can appear to be clinically stable. These fractures may be
treated with a splint only. This variant is somewhat rare.

Elderly, low-activity patients can have very high function and return to
prior activities even with a significantly displaced fracture. A 45° dorsal tilt can be
highly functional in a patient who does not drive and is not active outside the
home. Clinically, such patients have an unsightly wrist (with a prominent ulnar
head) that has limited supination and flexion, but they do not have symptoms with
ADLs. Success in these cases strongly depends on the patient, not the surgeon,
making the treatment choice.

A systematic review concluded that, in patients with DRFs who are aged
60 years and older, cast immobilization provided functional outcomes similar to
those achieved with surgical treatments (volar locking plate system, nonbridging
external fixation, bridging external fixation, or percutaneous Kirschner wire [K-
wire] fixation). Cast immobilization had the worst radiographic outcome yet the
lowest complication rate. Additional studies are needed to evaluate the recovery
rate, cost and outcomes of these treatment methods.

In 2009, the American Academy of Orthopaedic Surgeons (AAOS) issued a

clinical guideline on the treatment of DRFs. Many of the recommendations in the
guideline lacked strong supporting evidence and were considered inconclusive.
However, the following recommendations were supported by moderately strong
evidence:

 Rigid immobilization is suggested in preference to removable splints in

nonoperative treatment for the management of displaced DRFs

 For all patients with DRFs, a postreduction true lateral radiograph of the
carpus is suggested for assessment of DRUJ alignment

 Operative fixation is suggested in preference to cast fixation for fractures

with postreduction radial shortening greater than 3 mm, dorsal tilt greater
than 10º, or intra-articular displacement or stepoff greater than 2 mm

 Patients probably do not need to begin early wrist motion routinely after
stable fracture fixation

 Adjuvant treatment of DRFs with vitamin C is suggested for the

prevention of disproportionate pain

On the basis of the available evidence, the AAOS was unable to make a
recommendation for or against casting as definitive treatment after initial adequate
reduction or to recommend any specific surgical method over another.

Surgical Options

Traditionally, surgical treatment has been reserved for displaced,

irreducible DRFs or reducible but unstable DRFs. [17] One approach that is
becoming more popular is to provide surgical treatment to patients who cannot or
do not want to accept the constraints of cast treatment because of ADL, work, or
recreational concerns.
 No consensus has been reached as to which surgical treatment is best.
Several options are available, each with its own variations.

Prognosis

Unresolved treatment controversies notwithstanding, most patients can

resume their previous level of activity, including competitive sports. Most patients
will likely lose a few degrees of final flexion and extension, and possibly
supination as well; however, these limitations generally do not prevent full
function.

Although many cases have been reported in which return to function was
not limited by malunion or complications, patients are, in general, living longer
and continuing to be active longer than in previous generations, and this places
demands on the distal radius that were not seen previously. Consequently, even
with apparently good care, some patients are unable to resume their prior level of
functioning.

Nevertheless, all treatment approaches have a percentage of poor results,

with decreased supination, prominent ulnar heads, ligamentous problems, distal
radioulnar problems (usually instability), and degenerative joint disease being
common problems. These are the cases that prompt researchers to continue to
refine the techniques and devices.

Patients, however, want more concrete prognostic statements. To this end,

the following may be stated:

 Most patients treated with a volar fixed-angle plate can resume

nonforceful ADLs within 3 days to 2 weeks

 Patients treated with a cast have the cast removed at 6 weeks and can then
start ADLs

 Grip strengthening can often be started at 2 months after any type of

treatment, but forceful use of the hand should be delayed for 3 months
  Contact sports or activities in which the likelihood of falling on an
outstretched hand is high should be delayed for approximately 4 months

It should be kept in mind that these are just general guidelines and that
great variation exists among specific cases and specific physicians.

The long-term prognosis for a properly treated DRF is good, even with an
intra-articular fracture. If the articular surface is not comminuted and can be
reconstructed, osteoarthritis is rare. Wrist range of motion (ROM) will continue to
increase, and wrist tenderness with forceful use will continue to decrease even
beyond 2 years.

Complications

As a rule, DRFs heal quickly. Non union is usually not an issue; the most
common problem is malunion before or after treatment is initiated. Careful
attention to follow-up radiographs helps avoid this problem. Each type of
operative treatment has its own complications.