Distal radius fracture

1. Distal Radius Fractures

2. 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

3. 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.

4. Introduction
Classified by:
– presence or absence of intra-articular
involvement,
– degree of comminution,
– dorsal vs. volar displacement,
– involvement of the distal
radioulnar joint.

5. 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)

6. 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.

7. Treatment Goals
• Preserve hand and wrist function
• Realign normal osseous anatomy
– Articular surface
• Promote bony healing
• Allow early finger and elbow ROM

8. Osseous Anatomy
Distal radius – 80% of axial load
– Scaphoid fossa
– Lunate fossa
Distal ulna – 20% axial load
Sigmoid notch – DRUJ

9. 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 base of
ulnar styloid

10. Radial Inclination
• Inclination of radius towards the ulna
• measured by the angle between 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
• Average : 23 degree (13-30)

11. Radial Length
• Inclination of radius towards the ulna
• measured by 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
• Average : 11 mm (8-18)

12. Dorsal/Palmar tilt
• 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 perpendicular along
the longitudinal axis of the radius

13. Ulnar variance
• 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
• Measure of radial shortening
• Normal : -2 to +2 mm

14. Carpal Malalignment
• In 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.
• More than 2 mm of intra articular step off leads to articular
incongruity

15. Computed Tomography
Indications:
• Intra-articular fxs with multiple
fragments
• centrally impacted fragments
• DRUJ incongruity

16. Classification of
Distal Radius Fractures
Ideal system should describe:
– Type of injury
– Severity
– Evaluation
– Treatment
– Prognosis

17. Common Classifications
1.Gartland & Werley
2.Frykman (radiocarpal & radioulnar)
3.AO
4.Melone (impaction of lunate)
5.Fernandez (mechanism)

18. 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

19. Frykman Classification
Extra-articular
Radio-carpal
joint
Radio-ulnar
joint
Both joints
{
Same pattern
as odd
numbers,
except ulnar
styloid also
fractured
Importance of sigmoid
notch articular surface

20. Melone
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 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

21. AO/ OTA Classification

22. Classification – Fernandez (1997)
I. Bending-metaphysis fails under
tensile stress (Colles, Smith)
• extraarticular
II. Shearing-fractures of joint surface
• Intra articular
(Barton, radial styloid)
importance of mechanism and energy level of injury

23. Classification – Fernandez (1997)
III. Compression - intraarticular fracture
with impaction of subchondral and
metaphyseal bone (die-punch)
• Complex articular fracture & radial
pilon fracture
IV. Avulsion- fractures of ligament
attachments (ulna, radial styloid)
V. Combined complex - high velocity
injuries

24. 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

26. Indications for Closed Treatment
Low-energy fracture
Low-demand patient
Medical co-morbidities
Minimal displacement- acceptable
alignment

27. 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.

28. 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.

29. 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.

30. Prediction of Instability
1. Age > 80
2. Initial displacement of fracture (esp Radial shortening)
3. Extent of metaphyseal comminution
4. Displacement following closed reduction

31. Management of Redisplacement
• Repeat reduction and casting
– high rate of failure
• Repeat reduction and percutaneous pinning
• External Fixation
• ORIF

32. 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

33. Operative Management of Distal
Radius Fractures

34. 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

35. 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.

36. 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)

37. Percutaneous Pins

38. Percutaneous Pinning
2 radial styloid pins
Crossed Pins

39. Percutaneous Pinning-Kapandji
• intrafocal pinning through fracture site
• buttress against displacement

40. 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.

41. 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.

43. 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)

44. 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

45. 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

46. 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.

47. -
DORSAL
3rd DC –EPL
(extensile)
1-2nd DC
3rd compartment for dorsal
metaphysis or central articular
surface
between 5th and 6th for
ulnar styloid

48. VOLAR
Classical Henry approach Extended carpal tunnel approach
Useful for volar ulnar
corner fragment or
Fxs associated with
CTS

49. Volar –Henry Approach

51. Radial to FCR

52. Elevate Pronator
Quadratus

53. Volar Plating for Dorsal Fractures
-less tendon irritation than dorsal plating
- indirect reduction
-better tolerated than Ex fix

54. Fixed angle locked
screws

57. 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

58. • 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.

59. External fixation
• Method of choice for fractures with simple intra-articular
components and extensive metaphyseal
comminution.
• Types
– Bridging : Crosses radiocarpal joint
– Non bridging: Doesn’t cross radiocarpal joint

60. 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.

61. 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

62. Ligamentous Anatomy
Volar ligaments
– Straight fibers
– Stout
– Tighten readily
Dorsal ligaments
– Zigzag
– Elastic
– Tighten slowly

63. VOLAR
LIGAMENTS
MORE
STOUT
Dorsal
ligaments more
lax, zigzag

64. Pin Placement

65. Addition of percutaneous pinning improve the stability of external
fixation and prevent loss of reduction

66. full finger motion

67. 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

68. Limited indications
But shows good results

69. Early ROM permitted

70. 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

71. 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

72. Complications
Complication rates high
– Pin track infection
– RSD Finger stiffness
– Loss of reduction; early vs. late
– Tendon rupture

73. Thank You