2. ANATOMY
- The distal radius is biconcave,
triangular, and covered with
hyaline cartilage.
- The articular surface has two
facets for articulation with the
scaphoid, & lunate.
- The medial surface forms a
semicircular notch which
articulates with the ulnar head.
3. The distal radius and ulna articulate at
the radioulnar joint. The triangular
fibrocartilage (TFC )is a key stabilizer
of the distal radioulnar joint.
The pronator quadratus is associated
with an underlying fat pad seen as a
flat, lucent line on the lateral image.
4.
5.
6. Imaging
1- Posteroanterior (PA)
2- lateral
3-oblique radiographs: (reveal intra-articular
involvement)
A- The semisupinated, demonstrates the
dorsal facet of the lunate fossa.
B- The partially pronated, allows visualization
of the radial styloid.
7. Assessment of
Radiological parameters
1-Radial height (PA view)
Two Tangential Lines to the Styloid tip and
distal ulnar srurface normal is 11-13mm
2-Ulnar variance (UV) measured on PA
radiograph w/ wrist in neutral .
This image demonstrates ulnar plus
variance.
8. Ulnar variance is described as being zero( neutral) , minus, or plus.
Ulnar variance does not depend on the length of the ulnar styloid
but on the positioning of the forearm, & the radiographic
technique.
10. 4-The volar tilt, or palmar inclination, is
measured on the lateral view.
Slope of the dorsal-to-palmar surface of the
radius. The normal angle is 10-25º.
On the lateral view, the deep fat pad of the
pronator quadratus and the dorsal skin
subcutaneous fat line can be seen anterior
to the distal radius.
12. PATHOMECHANICS
Injury depends on the position of the wrist, the magnitude and direction of force,
and the physical properties of the bone.
A fall on the outstretched hand with the wrist in 40° to 90° of dorsiflexion produces a
distal radius fracture with dorsal displacement .
The lunate can exert a compressive force on the distal radius, producing a so-called die-
punch fracture .
The ulnar styloid fracture component of the Colles' fracture results from a force
transmitted through an intact triangular fibrocartilage complex.
13. PATHOMECHANICS
Fractures of the distal radius with palmar displacement are attributed
to more than one mechanism of injury.
1- A fall on the back of the flexed hand .
2- A fall on the outstretched extended hand. A fall with the forearm in
supination followed by pronation around a fixed extended wrist may
be the more common mechanism of injury.
14. PATHOMECHANICS
Radial styloid fractures result from an avulsion (tensile) force generated
through the palmar radiocarpal ligaments.
Careful evaluation of other ligamentous injuries (e.g., perilunate
dislocations )should be given to the patient with a radial styloid fracture.
15. CLASSIFICATIONS
UNIVERSAL CLASSIFICATION
Based on extraarticular versus intraarticular fractures and stable versus
unstable fractures.
FERNANDEZ AND JUPITER CLASSIFICATION
- most recent classification scheme
- identify stable versus unstable patterns,
- children's equivalent injuries,
- associated lesions,
- provide general recommendations for treatment
16.
17.
18.
19. FRYKMAN Classification of Distal Radius Fracture
Type Fracture
I Extraarticular radial fracture
II Extraarticular radial fracture with an ulna fracture
III Intraarticular fracture of the radiocarpal joint
without an ulna fracture
IV Intraarticular radial fracture with an ulna fracture
V Fracture of the radioulnar joint
VI Fracture into the radioulnar joint with an ulnar
fracture
VII Intraarticular fracture involving radiocarpal and
radioulnar joints
VIII Intraarticular fracture involving radiocarpal and
radioulnar joints with an ulnar fracture
20. Fracture Description
1- Location : Extra or Intra articular
2- Configuration : Simple : transverse or oblique/ Comminuted.
3- Displacement : Radial inclination
Radial length
Volar tilt
intra-articular incongruity
4- Ulna & DRUJ
21. Indication of Instability
1- > 10 degrees loss of angulation
2- > 5 mm of radial shortening
3- > 2mm of articular incongruity
4- comminution of cortex across the midaxial line on lateral x-ray
5- comminution of dorsal and palmar cotices
6- Irreducible fracture
7-Loss of reduction at follow up.
22. Complications of Distal Radial Fractures
1-Disruption of the triangular fibrocartilage (TFC) complex.
2-Scapholunate and lunotriquetral interosseous ligament injuries.
3- Ulnar nerve injury
4-Carpal tunnel syndrome
5-Posttraumatic radiocarpal osteoarthritis
6-Heterotopic ossification
7-Reflex sympathetic dystrophy (RSD)
8-Tendon rupture (extensor pollicis longus)
23. Epidemiology
Race
no racial preferences have been reported.
Sex
Older postmenopausal women, with a female-to-male ratio of 4:1. However,
in adolescent boys and girls, the ratio is 3:1,
Age
A bimodal age distribution
peaks occur at ages 5-14 years and at ages 60-69 years.
24. Indication for Reduction
1-Dorsal Tilt > 10 degrees
2-Articular Step off > 2 mm
3-Radial Shortening > 5 mm
4- Radial inclination < 15 degrees
25. Treatment Options
1- Closed Reduction
The initial treatment for most radius
fractures is closed reduction and
plaster immobilization.
The cast is usually maintained for
about 6 weeks
26. Non-acceptable reduction:
• Radial shortening > 5 mm
• Radial inclination < 10°
• Tilt on lateral projection > 10°
dorsal tilt and > 20° volar tilt
• Intra-articular step-off 2 mm or
more
• Articular incongruity 2 mm or
more of the sigmoid notch (articular
surface of distal radius in DRUJ).
27. 2- Surgical treatment
- Failure to obtain or maintain closed
reduction / or instable fracture pattern
- 40% of distal radial fractures are
considered to be unstable and require
surgical fixation.
- Surgical fixation allows almost
immediate mobility.
- Ultimately less stiffness and greater
function is possible.
28. Types of fractures
1- Colles’ fracture : Low energy
osteoporotic fracture
2- Smith’s fracture (Reversed Colles’):
similar to Colles’ but displaced anteriorly
rather than posteriorly.
3- Distal forearm fractures in children
4- Radial Styloid fracture :
5- Barton fracture : fracture subluxation
of the wrist .
6- Comminuted intra- articular fractures
in young adults.
29. Colles' fracture
A Colles' fracture is a fracture of the
distal metaphysis of the radius with
dorsal angulation and displacement
leading to a 'silver fork deformity
Colles fractures are seen more
frequently with advancing age and in
women with osteoporosis.
30. Lines of Closed treatment :
Mold the plaster splints
Frequent follow up with imaging
Immobilization of the wrist for a total of 6 weeks.
Removable palmar splint for an additional few
weeks.
31. Smith's fracture
-Occur in younger patients
- Result of high energy trauma
- Volar comminution and intraarticular
extension are more common.
32. Barton's fracture
Volar-type Barton's is a fracture-
dislocation of the volar rim of the radius.
Dorsal-type Barton's is a fracture-
dislocation of the dorsal rim of the radius.
Shear type fractures of the distal articular
surface of the radius
Have a great tendency for redislocation
and malunion.
Usually require operative treatment.
33. Die-punch fracture
- A depression fracture of the lunate
fossa of the distal radius.
- Result of a transverse load through the
lunate.
The radiographic findings can be very
subtle..
34. Chauffeur's fracture
(Hutchinson's)
- An isolated fracture of the radial
styloid process
- Displacement of the fragment is
uncommon.
- There can be associated injury to
the scapholunate ligament.
- Usually require surgical
treatment .
35. Ulnar styloid process fracture
- Usually associated with radial
fractures and rarely isolated.
- An isolated fracture of the tip is
clinically insignificant.
- Displaced fractures of the base are
usually associated with TFC tears and
can be associated with instability of
the distal radioulnar joint (DRUJ).
36. Fractures in Children
1- Torus (buckle) fracture
- Are extremely common injuries in
children.
- The word torus 'Tori' meaning
swelling or protuberance.
- Tend to heal much more quickly
than the similar greenstick fractures.
- Treatment : Short arm cast 3/52
37. Fractures in Children
2- Green stick fracture
- Only one part of the bone is broken
and the other side is bent.
- Tension side with plastic deformation
- reduce if angulation >10 degrees
- Can take a long time to heal because
they tend to occur in the middle, more
slowly growing parts of bone.
38. Fractures in Children
3- Epiphyseal fracture
-Usually Salter Harris type II
epiphysiolysis fractures
- Restoring of the anatomical
situation is necessary to prevent
growth disturbances.
- Redislocation is common after
closed reduction.
- In many cases they need
percutaneous pinning.
