1. DISTAL END OF RADIUS
FRACTURE AND DISLOCATION
MANAGEMENT
Dr Prateep Reddy
jr Resident-pg 1st year
Moderator Dr P Jaya Ram Reddy

2. 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
• 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,

4. • 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 Capito lunate
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
radio-lunate ligament.
• Displacement of this fragment is associated
with palmar displacement of the carpus and
also with loss of forearm rotation

5. • 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

6. ROLE OF TFCC(TRIANGULAR FIBROCARTILAGE COMPLEX)
• TFCC consists of articular disc, meniscus
homologue , dorsal and volar radioulnar
ligament, ulnocarpal ligament and ECU
sheath
• TFCC is the main stabilizer of distal
radioulnar joint in addition to
contributing to ulnocarpal stability
• TFCC normally not only stabilizes the
ulnar head in sigmoid notch of radius but
also acts as a buttress to support
proximal carpal row

7. ROLE PF TFCC
• 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 2.5mmincreases the load
transmission across the TFCC to 42%
• The TFCC excised the radial load increases to 94%

8. IMAGING
Plain x-rays
• Plain AP and lateral x-rays must
be taken for all DRFs.
• Oblique views and comparative
views of the other wrist can be
helpful.
• X-rays in high-energy trauma
should include the entire
forearm and wrist
Computed tomography
• A CT scan should be performed
when plain x-rays do not explain
the congruity and displacement
of the articular surface in the
sigmoid notch, lunate facet, and
the scaphoid fossa.
• The sigmoid notch is especially
well visualized by CT scan

10. SOME IMPORTANT MEASUREMENTS
• Palmar inclination :-
• angle subtended by the line
perpendicular to the long axis of
the radius and at second line drawn
from the dorsal lip to palmar lip of
distal radius. Average = 12°.

11. RADIAL HEIGHT (LENGTH)
• The distance between two parallel
lines drawn perpendicular to the
long axis of radial shaft: one from
the tip of the radial styloid and the
other from the ulnar corner of the
lunate fossa. Average = 12 mm.

12. ULNAR VARIANCE
• Is defined as the difference in axial length between the ulnar corner
of the sigmoid notch of the radius and the most distal extent of the
ulnar head on the PA view. Sixty percent of the population
is ulnar neutral

13. RADIAL INCLINATION
• The angle between two lines-
one drawn perpendicular to
the long axis of the radius at
the ulnar corner of the lunate
fossa and the other between
that point in the lunate fossa
and the tip of the radial
styloid. Average = 23°

14. 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 without the carpus

15. Common Classifications
• Column theory
• Frykman
• Weber (AO/ASIF)
• Malone
• Fernandez (mechanism)

16. APPLIED ANATOMY
• It consisting of three
distinct columns, each of
which is subjected to
different forces and thus
must be addressed as
separate elements

17. 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
degrees, 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

18. 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

19. ULNAR COLUMN
• The ulnar column consists of the ulna styloid but also should include
the TFCC and the ulnocarpal ligaments

21. AO Type
• A Extraarticular Type Partial articular
• B1-radial styloid fracture
• B2-dorsal rim fracture
• B3-volar rim fracture
• B4-die-punch fracture Type
• C Complete articular

23. MELONE CLASSIFICATION
• Depends on the impaction of the lunate on radial articular surface
• Type i- stable # without displacement
• Type ii-unstable 'die punch' with displacement of the characteristic
fragment and comminution of the ant and post cortices
• type ii A reducible type ii B:-irreducible

24. • Type iii- 'spike fracture’, unstable. Displacement of the articular
surface and also proximal spike of radius
• Type iv- 'split' fracture, unstable medial complex that is severely
comminuted with separation and or rotation of the distal and
proximal fragments
• Type v- explosion injury

25. Fernandez Classification
• I. metaphysis bending with loss of
palmar tilt and radial shortening
,DRUJ injury(Colles, Smith)
• II. Shearing-fractures of joint
surface (Barton, radial styloid)

26. • III. Compression-intraarticular
fracture with impaction of
subchondral and metaphyseal
bone (die-punch)
• IV. Avulsion-fractures of ligament
attachments (ulna, radial styloid)
• V. Combined/complex - high
velocity injuries

27. CLASSIFICATION
• There is perhaps no other fracture in the orthopaedics literature that
has garnered so many eponyms over time than fractures of the distal
radius
• Various eponyms are:
1. Colle's fracture
2. Smith's fracture
3. Barton's fracture
4. Chauffer's fracture/Hutchinson's fracture
5. Die punch fracture / lunate load fracture

28. COLLES FRACTURE
• extra articular or intra articular distal radius #
with various combination of
• dorsal angulation,
• dorsal displacement
• radial shift , and
• radial shortening-clinically described as
dinner fork deformity
• mechanism:-fall on to an hyper extended
,radialy deviated wrist with the
forearm in pronation

29. SMITH FRACTURE(REVERSE COLLES)
• # distal radius with volar
angulation or volar displacement
of the hand and distal radius
• mechanism—fall on to a flexed
wrist with the forearm fixed in
supination
• unstable pattern often requires
ORIF because of difficulty in
maintaining closed reduction

30. BARTON FRACTURE
• # dislocation or subluxation of wrist
in which the dorsal or volar rim of
distal radius is displaced
• mechanism-fall on to a dorsiflexed
wrist with the forearm fixed in
pronation
• unstable # requires ORIF

31. RADIAL STYLOID FRACTURE
• Avulsion # with extrinsic ligaments
remaining attached to styloid fragment
• Mechanism-compression of scaphoid
against styloid with the wrist in
dorsiflexion and ulnar deviation
• Often associated with intercarpal
ligament injury
• Requires ORIF

32. LUNATE LOAD/DIE PUNCH FRACTURE
• It is a intraarticular fracture with displacement of the medial articular
surface which usually represents a depression of dorsal aspect of
lunate fossa

33. Indications for Closed Treatment
• Low-energy fracture
• Medical co-morbidities
• Minimal displacement- acceptable alignment
• Closed Treatment of Distal Radial Fractures
• Obtaining and then maintaining an acceptable reduction.
• Immobilization:
• long arm
• short arm adequate for elderly patients
• Frequent follow-up necessary in order to diagnose re-displacement

34. Technique of Closed Reduction
• Anesthesia
• Hematoma block
• Intravenous sedation
• Bier block
• Traction: finger traps and weights
• Reduction Maneuver (dorsally angulated fracture):
• hyperextension of the distal fragment,
• Maintain weighted traction and reduce the distal to the proximal fragment with
pressure applied to the distal radius.
• Apply well-molded “sugar-tong” splint or cast, with wrist in neutral to slight flexion.

35. Acceptable Reduction Criteria
• Radial length- within 2-3 mm of the contralateral wrist
• Palmar tilt- neutral tilt(o degree )
• intraarticular step-off or gap< 2mm
• Radial inclination <5 degree loss
• Carpal malalignment – absent
• Ulnar variance- no more than 2 mm of shortening compare to ulnar head.

36. After-treatment
• Watch for median nerve symptoms
• paresthesia's 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.

37. SURGICAL MANAGEMENT
• Percutaneous pinning
• External fixation
• Open reduction and plate fixation
Dorsal plating
Volar plating
Distraction plate fixation

38. PERCUTANEOUS PINNING
• Percutaneous pinning: This is primarily
used for extra-articular fractures or
two-part intra-articular fractures.
• - It may be accomplished using two or
three Kirschner wires (K-wires) placed
across the fracture site, generally from
the radial styloid, directed proximally
and from the dorsoulnar side of the
distal radial fragment directed
proximally. Trans ulnar pinning with
multiple pins has also been described.

40. MODIFIED SAUVE-KAPANDJI
• The modified Sauve-Kapandji procedure involves resection of the
distal ulna with reinsertion of the bone into the distal radius after a
90-degree rotation
• The Sauve-Kapandji procedure can be performed for disorders of the
DRUJ after all fracture are healed and nonoperative
treatment has failed.

41. EXTERNAL FIXATION
• Types SPANNING EXTERNAL FIXATION
• NONSPANNNG EXTERNAL FIXATION
Spanning (bridging) external fixation
• Ligamentotaxis is used to restore radial length and radial inclination, but
it rarely restores palmar tilt.
• External fixation alone may not be sufficiently stable to prevent some
degree of collapse and loss of palmar tilt during the course of healing,
especially with comminuted fractures in osteopenic bone. Supplemental
K-wire fixation or bone graft can be used as adjunctive fixation.
• Over distraction should be avoided because it may result in finger
stiffness; The external fixator is removed after 6 to 8 weeks.

45. NONSPANNING
• 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.
• Indicated for extra articular or minimal intra
articular dorsally displaced fracture
• Minimum 1 cm of intact volar cortex is
required to give purchase for the pins
• Better to preserve volar tilt and carpal
malalignment

46. Internal Fixation of Distal Radius Fractures
• PALMAR PLATING
• The skin is incised longitudinally along the course of the
flexor carpi radialis (FCR) tendon.
• The FCR sheath is opened and the tendon retracted to the
ulnar side. Great care must be taken to avoid pressure on
the median nerve

49. DORSALAPPROACH
• Generally not preferred because of high rate of complication like
- tendon dysfunction and rupture
- tenosynovitis of extensor tendons
indications
• dorsal die-punch fractures or fractures with displaced dorsal lunate
facet fragments

51. DISTRACTION PLATE FIXATION
• Bridge plate of the wrist joint In
cases of extreme comminution,
where it is not possible to
reconstruct the joint, a temporary
joint spanning bridge plate across
the radiocarpal joint surface
may be considered.

52. CONCLUSION
• External fixators still have a role in the treatment of distal radius
fractures
• Spanning ex fix does not completely correct fracture deformity by
itself
• Should usually combined with percutaneous pins (augmented
fixation)
• Plating allows early wrist ROM
• Volar, smaller and more anatomic plates are better tolerated
• Quality of reduction more important than method of immobilization

53. REFFEREMCE
• AO MANUAL OF FRACTURE MANAGEMENT
• CAMBELL
• HAND BOOK OF FRCTURES