DISTAL RADIUS FRACTURES

Fracture Nomenclature for Distal Radius Fractures

Hand Surgery Resource’s Diagnostic Guides describe fractures by the anatomical name of the fractured bone and then characterize the fracture by the Acronym:

In addition, anatomically named fractures are often also identified by specific eponyms or other special features.

For the Distal Radius, the historical and specifically named fractures include:

Colles’ Fracture

Smith Fracture

Barton Fracture

Reverse Barton Fracture

Distal ulna fracture

By selecting the name (diagnosis), you will be linked to the introduction section of this Diagnostic Guide dedicated to the selected fracture eponym.

Distal radius fractures account for 12-17% of all fractures, which makes them the most common upper extremity fracture. These injuries occur most frequently in two age groups: in children and adolescents due to high-energy trauma, and in older patients with osteopenia or osteoporosis after low-to-moderate energy injuries. Despite the high prevalence of distal radius fractures and the continued emergence of new treatment options and techniques, universal consensus on the optimal management strategy is lacking. Many distal radius fractures—especially closed, stable, nondisplaced injuries—can effectively be treated conservatively with closed reduction and immobilization. Surgery is often required for open and severely displaced fractures, and for those that fail conservative treatment.^1-6,26-30

Definitions

• A distal radius fracture is a disruption of the mechanical integrity of the distal radius.
• A distal radius fracture produces a discontinuity in the distal radius contours that can be complete or incomplete.
• A distal radius fracture is caused by a direct force that exceeds the breaking point of the bone.

Hand Surgery Resource’s Fracture Description and Characterization Acronym

SPORADIC

S – Stability; P – Pattern; O – Open; R – Rotation; A – Angulation; D – Displacement; I – Intra-articular; C – Closed

S - Stability (stable or unstable)

• Universally accepted definitions of clinical fracture stability is not well defined in the literature.^7-9
• Stable: fracture fragment pattern is generally nondisplaced or minimally displaced. It does not require reduction, and the fracture fragments’ alignment is maintained by with simple splinting or casting. However, most definitions define a stable fracture as one that will maintain anatomical alignment after a simple closed reduction and splinting. Some authors add that stable fractures remain aligned, even when adjacent joints are put to a partial range of motion (ROM).
• Unstable: will not remain anatomically or nearly anatomically aligned after a successful closed reduction and immobilization. Typically unstable distal radius fractures have significant deformity with comminution, displacement, angulation, and/or shortening.
  • A distal radius fracture is further defined as unstable if it is unable to resist displacement after being anatomically reduced.¹⁰

P - Pattern

• Distal radial styloid
• Distal dorsal medial fragment
• Distal volar medial fragment
• Distal radial shaft

O - Open

• Open: a wound connects the external environment to the fracture site. The wound provides a pathway for bacteria to reach and infect the fracture site. As a result, there is always a risk for chronic osteomyelitis. Therefore, open fractures of the distal radius require antibiotics with surgical irrigation and wound debridement.^7,11,12

R - Rotation

• Distal radius fracture deformity can be caused by proximal rotation of the fracture fragment in relation to the distal fracture fragment.
• Degree of malrotation of the fracture fragments can be used to describe the fracture deformity.

A - Angulation (fracture fragments in relationship to one another)

• Angulation is measured in degrees after identifying the direction of the apex of the angulation.
• Straight: no angulatory deformity
• Angulated: bent at the fracture site
• Extreme dorsal angulation may be associated with triangular fibrocartilage complex (TFCC) injuries.¹⁰

D - Displacement (Contour)

• Displaced: disrupted cortical contours
• Nondisplaced: ≥1 fracture line(s) defining one or several fracture fragments; however, the external cortical contours are not significantly disrupted
• In distal radius fractures, displacement can be either extra-articular or intra-articular. Extra-articular displacement can occur in any of the 3 planes. When displacement occurs in the sagittal plane, it typically leads to loss of the palmar tilt, while volar shear injuries tend to increase palmar tilt. In the coronal plane, displacement typically manifests as the loss of radial inclination and/or height.¹³

I - Intra-articular involvement

• Intra-articular fractures are those that enter a joint with ≥1 of their fracture lines.
• Distal radius fractures can have fragment involvement with the radiocarpal joint or distal radioulnar joint (DRUJ).
• If a fracture line enters a joint but does not displace the articular surface of the joint, then it is unlikely that this fracture will predispose to posttraumatic osteoarthritis. If the articular surface is separated or there is a step-off in the articular surface, then the congruity of the joint will be compromised and the risk of posttraumatic osteoarthritis increases significantly.

C - Closed

• Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.^4-6

Distal radius fractures: named fractures, fractures with eponyms and other special fractures

Colles’ fracture^14-17

• Fractures of the distal radius were first accurately described by Abraham Colles as injuries that “take place at about an inch and a half above the carpal extremity of the radius” and “the carpus and the base of metacarpus appears to be thrown backward.” Although the eponym “Colles’ fracture” has been used to characterize this injury, more comprehensive, reliable, and prognostic classification systems have been introduced.
• A Colles’ fracture is an extra-articular, dorsally angulated fracture of the distal radius. The primary feature is dorsal displacement of the principal distal fracture fragment, and dorsal comminution, dorsal angulation, radial shortening, and associated ulnar styloid fractures are also common.^10,18
• Colles’ fractures are extremely common, accounting for more than 90% of all distal radius fractures and are one of the most common types of fractures seen in Emergency Departments.¹⁹
• These fractures frequently occur in older adults with osteoporosis secondary to a fall onto an outstretched hand (FOOSH) injury, which forces the wrist into supination.

Imaging

• Radiology studies - X-ray
• Radiology studies - Computerized tomography (CT) scanning
• Electrophysiological testing - EMG/NCV

Treatment

Conservative

• A treatment algorithm should be used to determine whether conservative treatment is sufficient or if surgery is required. This algorithm should be based on whether the fracture is displaced or non-displaced, stable or unstable, and intra-articular or extra-articular.
• Conservative treatment for Colles’ fractures typically involves closed reduction and immediate immobilization with a sugar-tong splint, followed by casting. This approach is particularly applicable to stable, non-displaced fractures or fractures without significant intra-articular deformity.

Operative

• Extrafocal percutaneous pinning
  • For extra-articular or simple intra-articular fractures.
• Arthroscopically assisted reductions
  • Can be used to assess joint congruity and associated ligamentous injuries.
• Open reduction and internal fixation (ORIF) with fragment-specific fixation
  • This technique uses low-profile implants to restore stability and articular congruity.
• ORIF with volar or dorsal plates for fixation
• Bone-graft substitutes
  • Options include autologous or allogenic cancellous bone graft, demineralized bone matrix, calcium phosphate-based void fillers, autologous bone marrow fillers.
• External fixation (bridging, non-bridging) with closed reduction

Complications

• Injury-related
  • Post-traumatic arthritis
  • Nerve injury
  • Stiffness
  • Failure to maintain reduction
  • Compartment syndrome
  • Skin tearing during reduction
  • Carpal tunnel syndrome
  • Extensor pollicis longus (EPL) or flexor pollicis longus (FPL) rupture
• Splint/cast-related
  • EPL rupture
  • Carpal tunnel syndrome
  • Loss of ROM
  • Post-traumatic arthritis in radiocarpal joint or DRUJ
  • Complex regional pain syndrome (CRPS)
• Surgery-related
  • Nerve injury
  • Soft-tissue injury
  • Infection
  • Late extensor or flexor tendon ruptures

Outcomes

• Worse outcomes are associated with axial shortening (>6 mm) during healing, comorbid injuries (eg, TFCC and scapholunate ligament tears), DRUJ instability, and work-related injuries.
• Fractures that heal with >20° of dorsal angulation, 10° of radial shortening, and/or 2 mm of articular incongruity also have a less favorable functional outcome.

Smith fracture

• Also known as a reverse Colles’ or volar Colles’ fracture, these are extra-articular distal radius fractures that involves volar displacement or angulation of a singular distal fragment.^1,10,18,20
• Although Smith fractures are the second most common type of distal radius fractures, they are significantly less common than the Colles’ fracture.²⁰
• Smith fractures most often occur either from a fall onto a flexed wrist—usually after falling backward and planting an outstretched hand behind the body—or due to a direct blow to the dorsal wrist. FOOSH injuries onto an outstretched palm may also be responsible in some cases.²⁰
• A Smith type II fracture, also known as a Reverse Barton Fracture or volar type Barton fracture, is an intra-articular fracture with volar displacement of the distal radius. These fractures involve the volar lip and occur with the wrist in palmar flexion.^3,20

Imaging²⁰

• Radiology studies - X-ray
  • Can help to differentiate between Colles’ and Smith fracture types.
  • Anteroposterior (AP) and lateral are usually sufficient, but traction, oblique, and fossa lateral views may be required in some cases.
• Radiology studies - Computerized tomography (CT) scanning
  • May be useful in the presence of extensive comminution or intra-articular fracture patterns.

Treatment^1,20

Conservative

• For non-displaced, stable Smith fractures, the conservative treatment of choice is closed reduction followed by immobilization.
• The wrist should be reduced and splinted in extension, and a thermoplastic splint or brace can be used for acute fractures.

Operative

• Surgical indications in Smith fractures include dorsal or volar comminution, intra-articular involvement, residual instability after reduction, surface angulation greater than 20°, articular surface step-off of >2 mm, and radial shortening of >5 mm.
• ORIF
  • Preferred surgical procedure for Smith fractures.
  • Best choice for unstable or non-reducible fractures.
  • Dorsal, volar, or fragment-specific
• Closed reduction with percutaneous pinning (CRPP)
• External fixation

Complications

• Malunion
• Garden spade deformity
• Pin track infection
• Pin loosening
• CRPS
• Carpal tunnel syndrome
• EPL rupture

Outcomes

• ORIF has been found to lead to significant improvements compared to conservative casting in cases of significant displacement or angulation, comminution, or in cases when the fracture remains unstable after reduction attempts.²⁰

Barton fracture

• This is a dorsally or volarly displaced intra-articular fracture of the distal radius that also involves a subluxation or dislocation of the radiocarpal joint. Displacement occurs due to a triangular fragment of the dorsal or volar margin of the distal radius being sheared off and displaced from the carpus.^1,10,18
• The Barton fracture is distinguished from Colles’ and Smith fractures because of the intra-articular radiocarpal joint involvement.¹⁰
• In pediatric and young adult patients, these injuries typically result from sporting activities and motor vehicle accidents. In older adults—particularly women—most Barton fractures result from falls in patients with osteoporosis.²¹

Imaging

• Radiology studies - X-ray
  • Frontal and lateral views are most important. Oblique views may also help in reaching a diagnosis.²¹
• Radiology studies - Computerized tomography (CT) scanning
  • May be utilized for better anatomic detail or when radiographs are unclear.²¹
• Magnetic resonance imaging - MRI without contrast

Treatment²¹

Conservative

• Non-displaced and stable Barton fractures should be treated with closed reduction and immobilization in a splint or cast; however, many of these fractures fail conservative treatment due to displacement. Therefore, most Barton fractures are treated surgically.
• An immobilization period of ≥6 weeks is typically required.

Operative

• The most common surgical intervention is closed reduction with external fixation, followed by percutaneous pinning.

Complications

• TFCC tears
• Carpal tunnel syndrome
• Forearm compartment syndrome
• CRPS

Outcome

• Although surgery is used more frequently for Barton fractures, research has shown that there are no significant differences in outcomes between conservative and operative treatment approaches.
  • When surgery is performed, outcomes are generally better in young patients than in older adults.²¹

Distal ulna fracture²²

• Isolated fractures of the distal ulna are relatively rare, but these injuries do frequently occur in conjunction with distal radius fractures.
• When distal ulnar and distal radius fractures occur concomitantly, the ulnar styloid is most commonly involved. Other injured structures may include the interosseous membrane (IOM), DRUJ, and TFCC. Due to the complex interaction between these bones and supporting structures, diagnosing and treating combined distal radius and ulna fractures is often challenging.

Imaging

• Radiology studies - X-ray
• Radiology studies - Computerized tomography (CT) scanning
  • May be needed to accurately define fracture fragments.
• Magnetic resonance imaging - MRI without contrast
  • May be considered if the physician suspects a TFCC injury or ligamentous disruption of the DRUJ.

Treatment

Conservative

• Conservative treatment is usually recommended for most ulnar styloid fractures, as well as for older adults with distal ulna metaphyseal fractures combined with a distal radius fracture and a stable DRUJ.
• Immobilization with casting may also be used for isolated distal ulna shaft and metaphyseal fractures with <50% displacement.

Operative

• In general, surgery is primarily recommended for the ulnar styloid if there is DRUJ instability or the fracture is comminuted and extends into the DRUJ.
• Ulnar styloid ORIF
• Fixation methods/hardware
  • Kirschner wires
  • Tension banding
  • Intraosseous wiring
  • Plate-screw constructs
  • Lag screw fixation

Complications

• Nonunion
• Neurapraxia
• DRUJ arthrosis
• Ulnar impaction

Outcomes

• Research suggests that functional outcomes for distal radius fractures are not negatively impacted by the presence of ulnar styloid fractures or failure to repair it.
• No method of fixation or immobilization has been found to be superior for isolated diaphyseal fractures.

Related Anatomy^1,23

• Distal radius, Radiocarpal joint, Lister’s tubercle and Distal radioulnar joint (DRUJ)
• The radius consists of a radial head and radial neck at its proximal end. The shaft of the radius then extends from the neck and has a rectangular epiphysis on its distal end. The articular—or lateral—surface of the distal radius is biconcave and triangular, and the apex of this triangle is directed toward the styloid process. On the medial surface, there is a concavity called the ulnar notch that articulates with the head of ulna, forming the DRUJ. The distal surface of the radius has two facets for articulation with the scaphoid and lunate carpal bones. There is also an articulation between the distal radius and the triquetral bone facilitated by a biconcave articular disc. Collectively, these three articulations form the radiocarpal joint.
• Ligaments associated with the distal radius include the dorsal radiocarpal ligament, which spans the ulnar aspect of the dorsal rim of the distal radius from the ulnar margin of the Lister tubercle to the sigmoid notch; the radioscaphocapitate ligament, which originates from the radial styloid and spans to the volar rim of the distal radius at the scaphoid fossa; the long radiolunate ligament, which originates from the volar rim of the scaphoid fossa; and the short radiolunate ligament, which originates from the volar rim of the lunate fossa.
• Tendons associated with the distal radius include those associated with the extensor carpi radialis brevis (ECRB), extensor carpi radialis longus (ECRL), and EPL muscles. The dorsal tubercle protrudes on the posterior aspect of the distal head of the radius and is seated between the grooves for the tendons of the ECRB and ECRL as well as the tendon of the EPL.
• The radius and ulna are connected by a sheet of thick fibrous tissue called the IOM.

Incidence

• Distal radius fractures are one of the most prevalent orthopaedic injuries and represent the most common of all upper extremity fractures, accounting for 12-17% of all fractures.^2,3,13
• Distal radius fractures follow bimodal age distribution during youth and adolescence (when high-energy trauma is usually responsible) and in older age (when low-to-moderate energy injuries usually lead to fractures in patients with osteopenia or osteoporosis).^4,5
• The risk for distal radius fractures is about 4-5 times greater in women than in men. Postmenopausal women have the greatest lifetime risk for these injuries, and approximately 10% of women aged ≥65 years will sustain a distal radius fracture at some point in the remainder of their lifetime.^2,5
• Osteoporosis accounts for ~250,000 wrist fractures annually

A typical patient is a 76-year-old woman with history of osteoporosis who injured her wrist from a fall. The woman was walking on the sidewalk and tripped on a raised section of pavement, which caused her to fall forward onto her hands. The impact of the fall forced her wrist into supination and resulted in a Colles’ fracture of the distal radius in her right wrist.  She was seen in an emergency room.  The doctor anesthetized her wrist and hung her arm in traction.  Next, the doctor pulled on her wrist, straightened the deformity, and placed her in a splint.  She now presents to the Hand Center complaining of less pain, moderate swelling, and mild tingling in her fingers.

• Malunion
  • Most common complication after distal radius fractures.
  • Malunion is more likely to occur in fractures treated with cast immobilization, in which the incidence is ~24%.¹³
• Posttraumatic osteoarthritis
  • Can occur in the radiocarpal joint or the DRUJ after certain distal radius fractures.
• Chronic osteomyelitis
  • Rare but can occur in open distal radius fractures, especially in patients with diabetes or in patients whose immune system is compromised.
• Carpal malalignment
• TFCC tears
• Carpal tunnel syndrome
• Forearm compartment syndrome
• CRPS
• Carpal tunnel syndrome
• EPL and FPL ruptures
• Non-union
• Neurapraxia
• Arthrosis
• Stiffness
• Splint/cast: EPL rupture (rare incidence about 3%), CTS, loss of range of motion, post-traumatic arthritis in RC or DRUJ joints, complex regional pain syndrome (CRPS)
• Percutaneous pinning: increases risk for injury to the superficial cutaneous branch of the radial nerve and damage or irritation to tendons of the first dorsal compartment
• Internal fixation: increases risk of soft tissue injury, infection and late extensor or flexor tendon ruptures

• Conservative treatment with cast immobilization has been associated with a high percentage of good to excellent outcomes, particularly in elderly patients. Research has also suggested that although surgery leads to better radiographic results, outcomes in the elderly population are similar between conservative and operative interventions.⁵
• One study compared ORIF to external fixation with pinning for displaced intra-articular distal radius fractures and found no statistically significant differences in radiological alignment or ROM at 2 years. Patients treated with external fixation and pinning also experienced a more rapid functional return and better functional outcomes than ORIF when intraarticular step-off and gap were minimal.²⁵
• Worse outcomes are associated with axial shortening (>6 mm) during healing, comorbid injuries (e.g., TFCC, scapholunate ligament tears), instability of the DRUJ, and work-related injuries
• Fractures that heal with >20¬∞ of dorsal angulation, 10¬∞ of radial shortening, and/or 2 mm of articular incongruity also have a less favorable functional outcome

Comment:

The goals of treating a distal radius fracture is to achieve a healed fracture which does not cause pain, allows a normal range of motion and has a normal or nearly normal external appearance. These goals do not always require a perfect looking X-ray but rather a healed aligned fracture that will allow the patient to function without pain and look reasonably normal. The treatment of the Colles' fracture should achieve these goals by using the simplest treatment method that will produce a result that meets these targets. If the fracture is nondisplaced, a simple splint followed by a cast once the swelling has subsided will often work well. If the fracture is displaced but can be reduced (manipulated under sedation and local anesthesia) so that the parts of the fracture are anatomically or nearly anatomically aligned, then a splint and cast will be adequate treatment if the reduction is stable (stays aligned). If the fracture cannot be reduced or held in a reduced position, then surgical treatment is indicated. If the fracture line goes into a joint and makes the joint incongruent (joint surface is not smooth), then aligning the fracture anatomically is even more important. An irregular joint surface can lead to early, painful post-traumatic osteoarthritis. The first level of surgical treatment maybe a reduction under anesthesia and pinning of the fracture followed by a splint and/or cast. Additionally, the fracture may have to be held in place by an external fixation device. If a closed reduction is inadequate, then an open reduction where the fracture fragments are surgically exposed and aligned will be needed. Once reduced and aligned anatomically, the fragments may be held in place by pins, screws, an external fixation device and/or internal fixation with screws and a plate. This type of open reduction and internal fixation (ORIF) is now commonly used for displaced and unreducible Colles' fractures. ORIF is also indicated for fractures with a displaced intra-articular component that must be aligned to prevent arthritis.

Points:

• Distal radius fractures must be immobilized before radiographic fracture healing is complete to avoid complications.
• Underlying pathological conditions such as bone tumor and osteoporosis should be expected in fractures that occur from trivial trauma.
• The functional needs of each patient must be considered when recommending treatment for distal radius fractures.
• While many distal radius fractures were managed conservatively in the past, the recent trend has been towards higher rates of surgical intervention. This uptick is largely due to advances in internal fixation techniques and devices.⁴
• Although distal radius fractures are among the most common musculoskeletal injuries, there is a lack of research that strongly supports one intervention over another. Therefore, treating physicians must carefully consider the advantages and disadvantages all available management options when making clinical decisions.^4,6
• Physicians must keep a high level of suspicion for associated soft tissue injuries to the intrinsic wrist ligaments when treating distal radius fractures.⁶
• Plain radiographs are the gold standard in diagnosing distal radius fractures. The standard views are: posteroanterior view, oblique view and lateral view.  Special views included: 10 tilt lateral view, lateral view with beam inclined 20°and 45° pronated oblique view. ^5,6
• Computerized tomography (CT) scanning can be valuable to ensure acceptable articular alignment when conservative treatment is being considered and during surgical planning for complex fracture patterns.^4,6
• Magnetic resonance imaging (MRI without contrast) is reserved for cases in which it is unclear whether a fracture is truly present, and to identify concomitant soft tissue pathology.⁶

Cited Articles

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