AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

Distal radius fractures account for approximately 15% of all fractures in adults. A thorough understanding of the pathophysiology and treatment of distal radius fractures is important because these injuries are not limited to just the elderly population. High-energy trauma to the distal radius in younger adults is becoming more prevalent, and long-term functional results are unclear. With an aging patient population that is increasingly active, these common injuries must be evaluated thoroughly and treated adequately.^{1, 2, 3, 4}

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Broken Arm.

(See also the eMedicine articles Forearm Fractures and Middle Third Forearm Fractures, as well as the article Diagnosis and Treatment of Forearm Fractures, on Medscape.) 

Etiology

The typical mechanism of a dorsally displaced distal radius fracture is a fall on an outstretched hand. This type of injury results in tensile forces across the volar surface (compression side), compressive forces on the dorsal surface (tension side), and supination of the distal fracture fragment. In the young adult, distal radius fractures are often caused by high-energy trauma. In the elderly patient, low-energy trauma, such as a fall from a standing height, can result in this injury.

Compression and torsion across the articular surface can cause various patterns of intra-articular displacement. Dorsal and palmar shear fractures of the medial complex are examples of compression applied to specific locations. Radial styloid fractures can be due to compression and/or torsion.

Pathophysiology

Mechanisms and relevant anatomy

The dorsal metaphysis of the distal radius is subject to tensile and compressive forces during routine forearm activities. The volar surface transmits higher compressive forces. Stable reduction of the distal radius fracture requires that this biomechanical relationship be reestablished. Accordingly, the volar buttress must be addressed first in unstable volar fractures (eg, volar Barton fracture, distal radius fracture with significant volar comminution). In the presence of volar comminution or inherently unstable volar vertical shear fractures, the key to stable fracture reduction is to create a solid volar buttress either by accurate reduction of large volar metaphyseal fragments or by placement of a volar buttress plate. Once volar stability is restored, the dorsal metaphyseal fragments can be reduced against the stable volar buttress.

Restoration of volar stability also has important radiocarpal implications because the stout radiocarpal ligaments are attached to the volar surface. Therefore, volar integrity is critical for the following reasons: (1) it allows reduction of dorsal metaphyseal fragments against a stable volar buttress and (2) it prevents possible radiocarpal instability.

Studies have shown that distal radius fractures often are associated with tears of the triangular fibrocartilage complex (TFCC), scapholunate ligament, and lunotriquetral ligament.^{5, 6} Geissler et al found that intracarpal soft-tissue injuries occurred most frequently with fractures involving the lunate facet.⁵ The lunate facet and its strong ligamentous attachments with the proximal carpal row and ulnar styloid form the medial complex of the distal radius as described by Melone (see Image 1).⁷ The carpus almost always is displaced with the palmar and/or dorsal lunate facet die-punch fragment of the distal radius because of the exceptionally strong ligaments of the medial complex.

Scapholunate dissociation can occur with severely displaced distal radius fractures, and the lunate displaces with the medial complex (lunate fossa), while the scaphoid remains with the radial styloid. The scapholunate diastasis usually corrects with reduction of the medial complex. Most of the disrupted soft tissues of the scapholunate articulation can heal with a period of immobilization, and Melone had no cases of subsequent chronic carpal instability.⁷

Scapholunate and lunotriquetral ligament injuries can occur in minimally displaced extra-articular fractures and in severely comminuted intra-articular fractures. The presence of central perforations of the scapholunate ligament and tears of the short radiolunate ligaments has important implications. Although these injuries do not result in scapholunate instability, Richards et al found false findings on arthrograms in 8% of patients in whom arthrography rather than arthroscopy was used for diagnosis.⁶ With arthroscopy, it is difficult to evaluate injury to the volar extrinsic ligaments, including the radioscaphocapitate and long radiolunate ligaments, because these ligaments may be pulled taut with the longitudinal traction necessary for entry of the arthroscope (Geissler, 1996).⁵

Distal radius fractures characterized by shortening and dorsal angulation are more likely to have a TFCC disruption, but preoperative radiographs have no predictive value in identifying specific interosseus ligament injuries. Intra-articular and extra-articular distal radius fractures commonly are associated with ligamentous injuries and tears of the radial aspect of the TFCC; however, disruption of the ulnar insertion of the TFCC is uncommon. The fact that certain intra-articular fracture patterns are associated with fewer TFCC injuries emphasizes the role that the TFCC plays in force dissipation and stability after a distal radius fracture.⁶

In general, the authors do not treat carpal ligament injuries, including the TFCC, that are associated with distal radius fractures that do not show visible deformities on plain radiographs. The authors believe that, with accurate fracture reduction, the ligaments heal during the postoperative or postreduction immobilization period. However, whenever an external fixator is applied, it must be used for neutralization only because excessive traction can displace or complete undiagnosed partial carpal ligament tears.

Classification

Burstein states that a classification system must suggest a method of treatment and provide a reasonably precise estimation of the outcome of that fracture. Furthermore, a classification system must have intraobserver repeatability and interobserver reliability.⁸

Although the Frykman system for classification of distal radius fractures has been used extensively in the medical literature, this classification fails to identify the direction and extent of fracture displacement.⁹ As a result, other classification tools have been developed, such as the Association for the Study of Internal Fixation (AO/ASIF), Melone, and Mayo systems. These systems classify the fractures on the basis of 4 distinguishing characteristics: extent of comminution, radiographic appearance or magnitude of displacement, articular joint involvement, and mechanism of injury.⁹

Andersen et al compared the Frykman, Melone, Mayo, and AO/ASIF classification systems and concluded that a low degree of intraobserver and interobserver agreement exists in each of these 4 systems. Consequently, the use of any of these classifications as the primary method to determine treatment and outcome of treatment is not warranted.¹⁰

Andersen et al also state, "Some orthopaedists have expressed concern, especially in training programs, that more effort is spent trying to memorize classification systems for a number of fractures, rather than truly understanding the fracture mechanics or the factors that have significant bearing on prognosis or treatment."¹⁰

Despite the negative aspects of the various tools for classifying distal radius fractures, the AO/ASIF system reached the "substantial level" for both interobserver and intraobserver agreement when these tools were reduced to 3 broad fracture categories¹⁰: extra-articular, partial articular, and complete articular. These 3 general fracture categories are incorporated in the classification system that the authors prefer and propose in the Table below.

Table. Classification and Treatment Guidelines for Distal Radius Fractures

Source.—Adapted from Beaty.¹¹

   ^*AR indicates arthroscopic reduction; BG, bone grafting of void (eg, iliac crest bone graft, allograft, bone graft substitute); CR, closed reduction; OR, open reduction; PP, percutaneous pinning.

   ^† Closed reduction with manipulation should be attempted on all displaced fractures, and surgery should be considered only in cases of inadequate closed reduction or loss of reduction with splint immobilization.

   ^‡Can be considered separately or in combination with other intra-articular fractures.

In looking at the radiographic characteristics of intra-articular fractures, the Melone 4-part pattern seems to be fairly reproducible. The basic fragments of the Melone 4-part pattern consist of the radial styloid, dorsal lunate facet die-punch fragment, palmar lunate facet die-punch fragment, and the radial shaft (see Image 2). Various combinations of these basic fragments of the Melone 4-part pattern are manifested consistently in intra-articular distal radius fractures. In addition to variability of fragment displacement, variability of comminution of each individual component fragment also exists.

Of historical interest, the Melone 4-part pattern can be viewed as the summation of the eponymous Colles, Smith, Barton, and chauffeur fractures.¹² The volar and dorsal vertical shear fractures (Smith II/volar Barton fracture and dorsal Barton fracture, respectively) have classically been described as partial articular injuries involving the lunate facet of the distal radius. These injuries include volar or dorsal carpal displacement because of the important extrinsic radiocarpal ligaments that attach to the lunate facet. As such, displaced volar and dorsal vertical shear fractures (Barton/Smith fractures) have the same biomechanical implications and treatment methods as displacement of Melone palmar and dorsal lunate facet die-punch fragments, respectively.

The authors' selection of treatment is based consistently on the particular configuration and displacement of the Melone fracture components. Because the goal of a good classification system is to define reproducible clinical characteristics that can guide treatment selection, the authors believe that their treatment algorithm can also serve as a practical classification system for distal radius fractures. This system is presented in the Table and further explained in Treatment.

If a dorsal lunate facet die-punch component does not have significant dorsal metaphyseal comminution, it can be reduced against the intact volar surface and stabilized by transfixing percutaneous pins (see Images 3-6). Inherent stability is restored with good dorsal cortical apposition. In highly comminuted dorsal fractures in which contact with the dorsal metaphyseal cortex is lost, inherent dorsal stability is established by using bone grafts as void fillers, in combination with external fixation, to maintain neutral tension in the dorsal aspect.

In the presence of unstable volar fragments, the anterior cortex cannot serve as an adequate anterior buttress against which the dorsal fragments can be reduced. In these instances, the authors routinely add a volar plate to stabilize the volar distal cortex (see Images 7-11). Thus, in cases with combined dorsal and volar instability, the dorsal fragments are treated as outlined above, but the volar cortex is reconstructed first with a volar buttress plate.

If a displaced radial styloid component is present, it is reduced manually and, if required, stabilized with 2 parallel radial styloid pins (see Image 6). Open reduction of the radial styloid may be necessary if closed reduction (CR) is not successful, and, in the presence of comminution and instability, volar radial plating of the radial styloid is an effective treatment option. Other treatment modalities, such as the use of small lateral buttress plates and clips are currently being investigated. Pronation or, more commonly, supination deformity of the radial styloid must be corrected. The use of intra-operative fluoroscopy is helpful in identifying rotation of the styloid fragment.

Thus, the classification system the authors prefer is a modification of the AO/ASIF and Melone systems that incorporates the various treatment principles described above. The classification system is derived from rational treatment-based options that the authors believe reflect the physiologic differences in each fracture pattern. The Table represents the authors' classification system and a practical guide for treatment of distal radius fractures.

Clinical

On presentation, history should include the patient's pertinent past medical history, occupation, hand dominance, mechanism of injury, and treatment history. The patient's dependence on the extremity for occupational needs and activities of daily living greatly affects later decision-making.

Start the physical examination proximally at the shoulder and continue distally to include the elbow, wrist, and hand. Visually inspect the wrist and note the presence or absence of open wounds, swelling, and deformity. Pain may limit manual examination and range of motion (ROM) of the injured wrist, but investigate other proximal injuries because they may alter the treatment plan. An adequate neurologic and vascular examination with particular attention to the median nerve is essential. Tests for compartment syndrome also must be performed carefully.

INDICATIONS

Section 3 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

Graham proposed the following radiographic criteria for acceptable reduction of a distal radius fracture¹³:

• Radial shortening less than 5 mm at the distal radioulnar joint (DRUJ) compared with the contralateral wrist.
• Radial inclination of more than 15° on a posteroanterior (PA) image.
• Sagittal tilt on the lateral projection between 15° dorsal tilt and 20° volar tilt.
• Intra-articular fracture step-off less than 1-2 mm of the radiocarpal joint.

Articular incongruity less than 2 mm of the sigmoid notch of the distal radius is another critical radiographic parameter.

Radial shortening has been shown to be the most important reduction parameter because of its impact on the radiocarpal joint, DRUJ, and, ultimately, functional outcome.^{13, 14, 7, 15, 16, 17, 18, 19, 20, 21, 22, 23} Palmer and Werner even found that minor axial shortening of 2 mm can alter the contact forces across the entire wrist joint.²⁰ Complications of radial shortening include increased pressure on the TFCC, pain caused by ulnocarpal impingement, increased lunate contact area, an increase of approximately 40% of the ulnar axial load, decreased and/or painful pronation or supination, and decreased grip strength.^{24, 25, 20, 14}

Radial inclination less than 15° can cause an appearance of radial deviation of the wrist and changes the load distribution between the scaphoid and the lunate.^{26, 20}

Most wrist fractures usually result in a dorsal tilt of the distal radius articular surface in the sagittal plane. Fernandez found that patients with a dorsal tilt more than 25° usually become symptomatic (Fernandez, 1982).¹⁸ Other authors have demonstrated that dorsal angulation is associated with decreased functional results.^{15, 16} Changes in sagittal tilt alter the biomechanics across the wrist joint. Pressure is dispersed over the entire articular surface of the distal radius and ulna at 11° of palmar tilt. As the sagittal tilt increases from 10° palmar tilt to 45° dorsal tilt, the axial load through the ulna increases from 21-67% of the total axial force. At 40° of dorsal tilt, most of the axial load is borne by the dorsal aspect of the radioscaphoid and ulnocarpal articulations without any load on the radiolunate joint.²⁷

Intra-articular step-off and gap on the distal radius articular surface has been studied extensively. It generally is agreed that more than 2 mm of articular displacement can lead to radiographic osteoarthritis (OA).^{28, 29, 30, 31, 32} However, radiographic OA does not always indicate poor functional outcome.^{28, 15, 33, 18, 34, 35}

Trumble et al adds that intra-articular fractures with more than 1 mm displacement should be treated aggressively because, for example, the wrist articular cartilage is not as thick as that of the knee .¹⁴ This decreased thickness of cartilage may consequently diminish the ability of the wrist to remodel residual articular incongruity.^{36, 32} Anatomic reduction of the articular surface is recommended to decrease radiographic OA and optimize functional outcome.^{28, 30, 25, 33}

In elderly patients, poor radiographic results do not necessarily signify poor functional outcomes.^{18, 34} Satisfactory functional outcomes, regardless of radiographic results, are observed in patients older than 60 years—not because they are older, but because of their lower functional demands. Therefore, nonoperative treatment of distal radius fractures can yield satisfactory outcomes, especially in patients with low functional demands and in patients who are poor operative candidates.^{34, 2}

RELEVANT ANATOMY

Section 4 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

See Pathophysiology.

CONTRAINDICATIONS

Section 5 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

There are no contraindications to the nonsurgical management of a closed distal radius fracture. Indications for surgical treatment should be based on radiographic findings after initial reduction, expected functional needs, associated medical conditions, and other traumatic injuries.

Open fractures also necessitate emergent surgical intervention and should be treated according to accepted principles. The decision for initial versus delayed placement of hardware should be based on the level of wound contamination and on the ability to achieve soft-tissue coverage over the implants

WORKUP

Section 6 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

Imaging Studies

• Initial radiographs of the distal radius should consist of good PA and lateral views. A good lateral view demonstrates that the anterior surface of the pisiform lies between the anterior surface of the capitate and the volar surface of the scaphoid tuberosity (see Image 12). The standard plain radiographs are important because they show the extent and direction of initial displacement, along with information about the DRUJ. Additional information is obtained later with traction (reduction) radiographs that can help demonstrate whether the distal radius fracture is intra-articular or extra-articular, and they can most readily reveal the degree of comminution. In addition to showing the degree of initial displacement, postreduction radiographs are extremely helpful for treatment planning.^{1, 37, 38}
• Measurements on the reduction radiographs should include the following: radial inclination (normal, 22°), radial length (normal, 12 mm), ulnar variance (normal, 0-1 mm), volar tilt (normal, 11°), articular step-off, and articular gap (see Images 13-15).³²
• The amount of acceptable articular step-off is debated, but most authors believe that less than 1-2 mm is desirable. Though long-term functional outcome has not yet been correlated with magnitude of articular step-off, the development of posttraumatic arthritis certainly has. Radial length is the measurement along the longitudinal radial axis between the tip of the radial styloid and the articular surface of the ulna styloid (see Image 14). This length is influenced by radial inclination and ulnar variance.¹⁶ As such, radial length indicates only the magnitude of longitudinal length discrepancy between the distal radius and ulna, not the specific cause.
• Changes in radial inclination and radial shift can result from the multiplanar displacement of the distal radius fracture. Pronation or, more commonly, supination of fragments is a frequent deformity that is difficult to measure directly with standard radiographs. Ulnar variance is influenced by metaphyseal comminution and shortening, forearm position, ulnar-head fractures, and/or fracture displacement of the medial aspect of the distal radius. Comparison views of the contralateral uninvolved wrist may assist in the evaluation of complex distal radius fractures.
• On plain radiographs, step-off and gap measurements can be imprecise for various reasons, including nonstandardized radiographic techniques, overlying radiopaque implants, soft-tissue shadows, and/or the complex structure of the distal aspects of the radius and ulna.²⁸ Cole et al has noted poor interobserver and intraobserver agreement in intra-articular step-off and gap measurements on plain radiographs of acute distal radius fractures. In the same study, 24% of the plain radiographic values indicated displacement of less than 2 mm, whereas CT scans indicated that the displacement was more than 2 mm. Conversely, significant displacement (>2 mm) was noted on 6% of the plain radiographs but not confirmed by the CT readings.³⁹
• Plain tomography or CT in the sagittal and coronal planes parallel to the longitudinal axis of the radial shaft is extremely helpful in quantifying the displacement and direction of an intra-articular fracture. These techniques are also useful when the fracture pattern is difficult to visualize on plain radiographs. CT scanning is strongly recommended for defining the intra-articular fracture pattern, especially those associated with die-punch fractures, volar rim fractures, and fractures involving the scaphoid facet (which can be more difficult to assess on plain radiographs).³² The authors routinely obtain CT scans before operating on displaced intra-articular fractures.

TREATMENT

Section 7 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

Medical therapy

Stable fractures

Closed treatment methods are indicated for stable fractures. Stability is predicated on accurate reduction and adequate bony integrity to maintain that reduction. Surgical treatment may be necessary for injuries that are identified as unstable.

Nondisplaced extra-articular and intra-articular fractures

For nondisplaced extra-articular and intra-articular fractures of the distal radium, immobilization without fracture manipulation is recommended. Experience has demonstrated that a circular cast or even a bivalved cast has the potential for complications, such as compartment syndrome and swelling of the digits. A padded sugar-tong plaster splint with 20-30° of wrist palmar flexion and neutral rotation is a safe alternative, and the elastic bandages around the sugar-tong plaster splint can be adjusted later to accommodate decreased swelling, without manipulation of the fracture.

Three-point molding is an important aspect of the sugar-tong plaster splint because this helps maintain reduction of the fracture. Appropriate molding along the dorsal distal radius, volar distal forearm, and dorsal proximal forearm helps achieve adequate 3-point molding. The authors have found that a flat surface of the splint along the volar distal forearm is key to achieving 3-point molding (see Images 16-19).

The sugar-tong plaster splint with its U shape around the elbow prevents pronation and supination but allows some elbow motion. Elimination of pronation and supination neutralizes deforming forces (eg, brachioradialis) on the fracture fragments. Wrinkles in the splint must be avoided, especially on the volar side because such wrinkles can cause local compression of the median nerve, carpal tunnel, and volar skin. Conversion to a short arm circular cast is not always necessary or recommended; however, if it is necessary, it should be done at 2-4 weeks after sugar-tong plaster splint immobilization.

Plain radiographs should always be obtained after splinting to confirm that the fracture fragments are not displaced. Radiographs should be acquired every week for 2-3 weeks after immobilization to ensure stability of the fracture. Maintaining the wrist above the level of the heart and early finger motion facilitate rapid improvement of swelling. During the period of immobilization, finger motion and "six-pack" finger exercises, as Palmer describes (see Image 20), are important and should be performed at least 3 times a day. These exercises emphasize finger extension, metacarpophalangeal joint flexion, proximal interphalangeal joint flexion, full finger flexion, finger abduction and adduction, and thumb motion.⁴⁰

After immobilization for a total of 4-6 weeks, the recovery of pronation and supination and wrist flexion and extension should be emphasized. Occupational therapy may be necessary during or after immobilization if the patient has difficulty with finger motion or wrist motion, respectively. Strenuous activities with the affected wrist should be restricted for the first 3 months after injury.

Displaced extra-articular and intra-articular fractures

All displaced distal radius fractures should initially be treated with CR and fracture manipulation and immobilization in a sugar-tong plaster splint (see Images 18-19). Even if adequate reduction is not achieved, the initial CR limits injury to the nerves, tendons, and soft tissues as a result of the displaced bone fragments. Manipulation of the fracture can be achieved in the emergency room or outpatient clinic by using a hematoma block and/or sedation or by using a Bier block.⁴¹ Local hematoma block without sedation is believed to be a safe option in the outpatient setting and can be performed as long as 7-10 days after injury.

Longitudinal traction with finger traps is helpful during CR, and if used, the traction should be maintained for several minutes before fracture manipulation to take full advantage of ligamentotaxis and tissue creep. Plain radiographs and, ideally, fluoroscopic images can be used to assess the fracture reduction with traction. If the reduction is inadequate, the fracture can be easily manipulated again.

Articular congruity of the sigmoid notch of the distal radius is just as essential as that of the radiocarpal joint. If the fracture line involves the sigmoid notch, motion arthroplasty of the sigmoid notch can be achieved by pronating and supinating the forearm during the reduction maneuvers. Adequate reduction of the sigmoid notch must also be evaluated on traction and postreduction views.

If adequate reduction is achieved with fracture manipulation, a sugar-tong plaster splint should be applied, with the longitudinal traction in place. As the splint is setting up, the longitudinal traction can be released, and the dorsal and palmar 3-point molding of the sugar-tong plaster splint can carefully be completed with light manual traction. The wrist should be placed in 20° volar flexion, neutral rotation, and 15° ulnar deviation to take advantage of ligamentotaxis and 3-point molding. Once the splint is hard, manual traction is released and plain radiographs ordered. Continue the immobilization if the radiographs demonstrate maintained reduction, but operative treatment should be considered if the fracture becomes displaced in the splint. Scheduled follow-up visits with plain radiography are essential in the treatment of distal radius fractures.

If adequate reduction criteria are not achieved, surgical intervention is necessary, as outlined in the Table. In the interim before surgery, sugar-tong plaster splinting can be used to immobilize the fracture and limit damage to surrounding structures. High-energy injuries are often associated with extensive swelling, and operative intervention should be performed after swelling has decreased, usually several days after injury.³²

Unlike nondisplaced fractures of the distal radius, fracture displacement implies more injury to the soft-tissue envelope; therefore, splint immobilization should be continued for a minimum of 6 weeks or longer.^{19, 42} Conversion to a short arm cast can be considered after 4-6 weeks of immobilization. Wrist immobilization, if applied properly, can be maintained for 6-8 weeks without additional adverse effects on the long-term functional outcome.³⁵ After cessation of immobilization, the same protocol as for nondisplaced fractures must be followed.

Surgical therapy

Surgical treatment is indicated for unstable distal radius fractures. An unstable injury is defined as a fracture that does not reduce adequately with closed fracture manipulation or that loses reduction below acceptable reduction parameters despite appropriate immobilization techniques.

Dorsally displaced extra-articular fractures

CR and percutaneous pinning is a simple and effective treatment for dorsally displaced extra-articular fractures with large metaphyseal fragments. Cross pinning with 0.062-inch diameter smooth pins in the radial styloid (2 pins) and dorsal ulnar aspect of the distal radius (1 pin) has been shown to be a rigid construct in both torsion and cantilever bending (see Images 5-6).⁴³ The radial styloid is anterior so the radial styloid pins are to be directed in a dorsal proximal ulnar direction.⁹ To avoid injury to the extensor tendons, the percutaneous pin should be inserted between the extensor tendons of the first and second, third and fourth, and/or fourth and fifth compartments (see Image 21).⁴⁴

Intrafocal (Kapandji) pins are another consideration, especially in the physiologically younger patient, but they should not be used initially in the presence of significant comminution or advanced osteopenia.^{23, 45, 44} This technique is especially useful for reducing and holding fractures that redisplace after several weeks of immobilization.

Extensive comminution at the fracture site can occur in physiologically young patients involved in high-energy injuries and in osteoporotic patients with low-energy trauma. When these fractures are reduced, the metaphyseal bone has resultant voids, which require filling with iliac crest bone grafts, allografts, or bone-graft substitutes.

McBirnie et al found a 22% malunion rate in unstable distal radius fractures treated with bone grafting and fixation with a single Kirschner wire.⁴⁶ This rate suggests that additional support, as with an external fixator or plate, is necessary with this type of treatment. The authors do not use dorsal plates for acute fractures, because some plates can irritate the extensor tendons, and they frequently have to be removed. Newer low-profile plates and screws are now available. New external fixators are easy to apply in neutral tension and can be used for fine-tuning difficult reductions. In association with dorsal bone grafts, external fixators maintain neutral tension in the dorsal aspect and can be removed early (4 wk) in some fractures.

Bone-void filler provides mechanical support and applies an osteoconductive material to the bone defect.^{47, 48, 14, 25} The use of filler ultimately leads to more rapid fracture healing and a decreased incidence of the loss of reduction.

Volarly displaced extra-articular fractures

Like its dorsal counterpart, a volar displaced fracture with noncomminuted metaphyseal fragments responds well to CR and percutaneous pinning, which effectively restores the volar buttress in the presence of large volar metaphyseal fragments. The use of dorsal intrafocal pins for stabilization is controversial because they may aggravate the volar displacement and not restore anatomic alignment. Proper palmar tilt is readily achieved with CR; however, excessive palmar tilt is still possible if volar metaphyseal fragmentation is not properly evaluated on initial radiographs.

With small, comminuted, volar metaphyseal fragments, compression of cancellous bone is expected, with resultant loss of the essential volar buttress. Volar plating stabilizes the fracture, and a bone-void filler may be added. Rigid fixation with a volar plate also permits early ROM out of the plaster splint.

Unlike small-fragment dorsal comminution, small-fragment volar metaphyseal comminution cannot be treated with ligamentotaxis because of the radiocarpal ligamentous anatomy. The volar ligaments are shorter, thicker, and stronger than the longer, thinner, and weaker dorsal ligaments. The stout volar ligaments tighten sooner with longitudinal distraction, resulting in dorsal tilt of the distal fragment.^{49, 50, 35, 51} The volar capsule should not be opened because of these strong volar ligaments, which are important for radiocarpal stability.⁹ These observations further support the authors' use of a volar plate to reconstruct the volar buttress in the presence of significant volar metaphyseal fragmentation.

Intra-articular fractures

Intra-articular fractures involving dorsal and/or volar metaphyseal fragments are a combination of intra-articular and extra-articular displaced injuries. As such, their treatment plans are additive. Ideally, all intra-articular fragments should be anatomically reduced to retard the development of OA. CR and splint immobilization techniques are similar to those used for extra-articular fractures.

Dorsally displaced lunate facet die-punch fractures

Dorsally displaced lunate facet die-punch fractures need to be anatomically reduced (with either an open or closed technique) to realign the radiolunate joint and the sigmoid notch and to restore the integrity of the medial complex. The dorsal ulnar fragment can be treated with closed reduction and stabilized with a single pin. However, a limited dorsal open reduction between the fourth and fifth extensor compartments may be necessary (see Images 5-6, Image 21).²⁵

If the dorsal metaphyseal fragments are small (comminuted), dorsal bone grafts (or substitutes) and external fixation are recommended, as described for extra-articular comminuted fractures. In either case, the intact volar cortex serves as a buttress against which stability of the dorsal fragment is maintained.

Volarly displaced lunate facet die-punch fractures

The volar fragment of the coronal split has a tendency to rotate dorsally when tension is applied to the volar capsule, and such displacement requires a volar open reduction. If this occurs, the volar medial fragment is buttressed with a small plate (see Images 7-11). Volar plating does not have the same complications as the dorsal plate and does not necessitate routine early hardware removal.

Dorsal and volar metaphyseal fragments

When displacement (instability) of dorsal and volar metaphyseal fragments is present, dual approaches are necessary. As always, a stable volar buttress is critical for providing a fulcrum against which the dorsal fragments are reduced. Volar plating provides this stability and prevents excessive volar displacement secondary to manipulation of dorsal fragments and/or placement of bone grafts.⁴⁶ When dual incisions are necessary, an attempt should be made to close the volar incision before the dorsal incision is made to minimize tissue swelling and to limit skin tension with wound closure.³²

Radial styloid fractures

The isolated radial styloid fracture (ie, chauffeur's fracture) is uncommon. When present, this fracture should be critically evaluated for associated injuries, such as a scaphoid facet die-punch fracture and, more importantly, a carpal ligament injury.³²

This fracture responds well to CR and can successfully be pinned percutaneously (see Images 3-6).²⁵ However, if small metaphyseal fragments are present or if CR is not successful, open reduction internal fixation through either a direct dorsal approach or a standard volar (Henry) approach must be considered. The latter is chosen when the styloid fragment is displaced volarly or when it has a large volar extension.

Most often, the styloid fragment is part of a 4-part displacement pattern, as Melone described.⁷ In this instance, the treatment of all components is additive. The reduction and stabilization of the radial styloid, dorsal lunate facet die-punch, and volar lunate facet die-punch fractures are assessed and treated as described above, either individually or in combination.

Central depression fractures

Central depression of lunate or scaphoid facets should be evaluated with CT scanning or plain tomography to fully assess the magnitude of articular step-off. Impacted fractures more than 1-2 mm should be treated with reduction via a limited dorsal approach, with bone grafting for mechanical support, and with percutaneous pinning for stability.^{25, 52} The reduction can be confirmed by means of fluoroscopy or, more precisely, by direct visualization (capsulotomy) or arthroscopy. Arthroscopically assisted reductions have the advantage of minimizing capsular scarring; however, no available data show that arthroscopy improves outcomes.³²

COMPLICATIONS

Section 8 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

Early complications

Distal radius fractures can directly or indirectly cause contusion, laceration, and/or entrapment of skin, tendons, nerves, fascia, muscle compartments, and vessels by bone fragments.⁵³ The potential for early soft-tissue complications increases with any delay in initial treatment; therefore, early initial reduction of the fracture can minimize the effects of these associated injuries.

Iatrogenic injury must also be avoided regardless of whether treatment is conservative or surgical. Cast treatment can lead to skin pressure necrosis and median nerve compression.⁵³ Joint contractures are associated with the Cotton-Loder position (ie, excess palmar flexion with ulnar deviation).⁷ Circumferential casts or dressings cannot allow for expected swelling, and compartment syndrome can subsequently occur.⁵³ Persistent finger edema can also result in stiffness of the digits. Casts that block finger motion are unnecessary and potentially harmful.

Surgical management of distal radius fractures can also result in complications. Percutaneous placement of pins is technically simple but can easily injure extensor tendons and nerves.⁵⁴ Excessive traction by external fixation can lead to joint stiffness and injury of carpal ligaments.⁵⁰ Careful handling of soft tissues in all surgical approaches is essential to prevent postoperative skin damage and infection.

Caution should be used when bone grafts are used in intra-articular fractures to avoid intra-articular extravasation. Rupture of the extensor pollicis longus (EPL) can occur with surgical or nonsurgical treatment. Careful reduction of dorsal fragments helps to avoid this complication. In dorsal approaches to the wrist, releasing the EPL tendon from its compartment can also help to avoid tendon constriction and injury.

Early reflex sympathetic dystrophy (RSD) should always be suspected in the presence of inappropriate postoperative pain, swelling, and stiffness. RSD may be caused by tight dressings, unresolved nerve injury (eg, carpal tunnel syndrome), or inherent patient susceptibility to this complication. In any event, early recognition and treatment is effective in most cases. Removal of the instigating factors, active ROM of thumb and fingers, sensory stimulation, activities of daily living of the hand, and psychotropic medication all have beneficial effects.

Long-term complications

The list of long-term complications associated with distal radius fractures is extensive and not within the scope of this article. This section provides a general overview of the common problems. Pain and extremity function should guide the treatment plan; radiographic findings guide the surgical approach.

Extra-articular malunion is often multidirectional and can result in malalignment of the DRUJ and the carpal bones. Typically, extra-articular malunions are shortened and tilted dorsally and treated with distal radial osteotomy, corticocancellous bone grafting, and dorsal-plate fixation. On correction of the distal radius alignment, the radial length and reduction of the DRUJ must be critically assessed.

Further considerations include ulnar shortening, distal ulnar ablation (Darrach), partial distal ulnar resection with or without interposition arthroplasty, or distal radioulnar fusion with ulnar pseudarthrosis (Sauve-Kapandji). Many of these DRUJ procedures can be performed without correction of the distal radius malunion.^{13, 55, 17, 18}

Although many patients report excellent results after reconstruction of distal radius malunions (particularly DRUJ malalignment), data from good long-term outcome studies are unavailable. An intra-articular step-off more than 2 mm can lead to degenerative arthritis, but these radiographic findings have not been correlated with long-term patient outcomes.

Following treatment of distal radius fractures, functional impairment is possible for as long as 2 years. For this reason, the authors continue aggressive therapy, including active and active-assisted ROM, progressive-resistance exercises, and work rehabilitation for as long as improvement is noted objectively. Only then is it appropriate to assess the need for reconstructive surgery.

OUTCOME AND PROGNOSIS

Section 9 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

Fractures of the distal radius are not simple injuries and, thus, require careful evaluation of the radiocarpal joint, the DRUJ, and carpal bones. However, educated decision making based on objective data and patient profile can lead to optimal outcomes of these challenging fractures.

The prognosis is dependent on the functional expectations of the patient, and as such, anatomic restoration of the distal radius and early radiocarpal joint mobilization are important for patients with high functional demands.

The magnitude and direction of displacement and the type of fragmentation at the fracture site are important factors determining the treatment plan; such treatment recommendations based on these critical parameters is presented in the Table. Important aspects of this classification system can be summarized as follows:

• An intact volar buttress is the key to a stable reduction. When disrupted, this buttress must be restored.
• All intra-articular fractures have 1 or more components of the Melone 4-part pattern, and each component must be addressed and stabilized.
• Dorsal bone grafting is an important adjunct in promoting stability and healing when dorsal metaphyseal comminution is present.
• External fixation should be used in conjunction with dorsal bone grafting when dorsal comminution is present. The external fixator should be used as a neutralization device and can be removed early (4 wk) when used in this fashion.
• Every patient is unique, and the ultimate treatment plan should be based on individual needs and expectations.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

Media file 1:  The medial complex, as described by Melone, consists of the lunate facet and its ligamentous attachments, especially the strong volar ligaments. Displacement of the medial complex has important functional implications.
	View Full Size Image
Media type:  Image

Media file 2:  The basic fragments of the Melone 4-part pattern consist of the radial styloid, dorsal lunate facet die-punch fragment, volar lunate facet die-punch fragment, and radial shaft. Note that displacement of the dorsal and/or volar lunate facet die-punch fragments also alters the anatomy of the sigmoid notch articular surface; thus, it has important consequences for forearm pronation and supination.
	View Full Size Image
Media type:  Image

Media file 3:  Lateral radiograph demonstrates a distal radius fracture with dorsal fragmentation (same patient in Images 3-6).
	View Full Size Image
Media type:  X-RAY

Media file 4:  Posteroanterior (PA) radiograph demonstrates a distal radius fracture with a nondisplaced intra-articular fracture between the lunate and scaphoid facets (same patient in Images 3-6).
	View Full Size Image
Media type:  X-RAY

Media file 5:  Reduction of the distal radius fracture is maintained with 3 percutaneous wires. The dorsal metaphyseal fragmentation did not require bone grafting in this case (same patient in Images 3-6).
	View Full Size Image
Media type:  X-RAY

Media file 6:  The radial styloid fragment is stabilized with 2 percutaneous wires, and a single pin is used to maintain the reduction of the lunate facet fragment. This cross-pinning technique provides a rigid construct for distal radius fractures (same patient in Images 3-6).
	View Full Size Image
Media type:  X-RAY

Media file 7:  Lateral radiograph of the wrist demonstrates volar metaphyseal displacement, which implies loss of volar integrity (same patient in Images 7-11).
	View Full Size Image
Media type:  X-RAY

Media file 8:  Anteroposterior (AP) plain radiograph shows a subtle sagittal intra-articular fracture of the distal radius (same patient in Images 7-11).
	View Full Size Image
Media type:  X-RAY

Media file 9:  CT scan demonstrates an important volar rim injury and a sagittal intra-articular fracture of the distal radius (same patient in Images 7-11).
	View Full Size Image
Media type:  CT

Media file 10:  Postsurgical lateral radiograph shows a good reduction of the fracture with a volar buttress plate (same patient in Images 7-11).
	View Full Size Image
Media type:  X-RAY

Media file 11:  Anteroposterior (AP) postsurgical radiograph shows reduction of the fracture with a volar buttress plate (same patient in Images 7-11).
	View Full Size Image
Media type:  X-RAY

Media file 12:  An adequate lateral radiograph demonstrates that the anterior surface of pisiform lies between the volar surface of the scaphoid tuberosity and the anterior surface of the capitate.
	View Full Size Image
Media type:  X-RAY

Media file 13:  The normal radial inclination is 22°.
	View Full Size Image
Media type:  Image

Media file 14:  The normal radial length (RL) is 12 mm, and the ulnar variance (UV) is usually neutral or negative (normal, 0-1 mm).
	View Full Size Image
Media type:  Image

Media file 15:  Lateral radiographic view demonstrates the volar tilt (normal, 11°).
	View Full Size Image
Media type:  Image

Media file 16:  Lateral views show a distal radius fracture with dorsal displacement (same patient in Images 16-19).
	View Full Size Image
Media type:  X-RAY

Media file 17:  Posteroanterior (PA) views show an intra-articular distal radius fracture with displacement of the dorsal lunate facet die-punch fragment (same patient in Images 16-19).
	View Full Size Image
Media type:  X-RAY

Media file 18:  Closed reduction, fracture manipulation, and motion arthroplasty of the sigmoid notch were performed under a local hematoma block. Note the flat surface of the splint along the volar distal forearm to achieve 3-point molding of the sugar-tong plaster splint (same patient in Images 16-19).
	View Full Size Image
Media type:  X-RAY

Media file 19:  Postreduction posteroanterior (PA) view demonstrates an adequate stable reduction of fracture fragments; thus, surgical intervention was not required (same patient in Images 16-19).
	View Full Size Image
Media type:  X-RAY

Media file 20:  "Six-pack" exercises as Palmer describes, are performed during the period of immobilization to encourage and maintain finger motion.
	View Full Size Image
Media type:  Image

Media file 21:  Safe pin placement is possible on the dorsal distal radius between the first and second, third and fourth, and/or fourth and fifth extensor compartments.
	View Full Size Image
Media type:  Image

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Multimedia
• References

1. Lashin H, Davie MW. DXA scanning in women over 50 years with distal forearm fracture shows osteoporosis is infrequent until age 65 years. Int J Clin Pract. May 29 2007;[Medline].
2. Nordell E, Kristinsdottir EK, Jarnlo GB, Magnusson M, Thorngren KG. Older patients with distal forearm fracture. A challenge to future fall and fracture prevention. Aging Clin Exp Res. Apr 2005;17(2):90-5. [Medline].
3. Mulherin D, Williams S, Smith JA, Edwards J, Sheeran TP, Price T. Identification of risk factors for future fracture in patients following distal forearm fracture. Osteoporos Int. Sep 2003;14(9):757-60. [Medline].
4. Lofthus CM, Frihagen F, Meyer HE, Nordsletten L, Melhuus K, Falch JA. Epidemiology of distal forearm fractures in Oslo, Norway. Osteoporos Int. Nov 6 2007;[Medline].
5. Geissler WB, Freeland AE, Savoie FH, et al. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am. Mar 1996;78(3):357-65. [Medline].
6. Richards RS, Bennett JD, Roth JH, Milne K Jr. Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures. J Hand Surg [Am]. Sep 1997;22(5):772-6. [Medline].
7. Melone CP Jr. Articular fractures of the distal radius. Orthop Clin North Am. Apr 1984;15(2):217-36. [Medline].
8. Burstein AH. Fracture classification systems: do they work and are they useful?. J Bone Joint Surg Am. Dec 1993;75(12):1743-4. [Medline].
9. Jupiter JB, Fernandez DL. Comparative classification for fractures of the distal end of the radius. J Hand Surg [Am]. Jul 1997;22(4):563-71. [Medline].
10. Andersen DJ, Blair WF, Steyers CM Jr, et al. Classification of distal radius fractures: an analysis of interobserver reliability and intraobserver reproducibility. J Hand Surg [Am]. Jul 1996;21(4):574-82. [Medline].
11. Beaty JH, ed. Orthopaedic Knowledge Update 6. Rosemont, IL American Academy of Orthopaedic Surgeons. 1999: 364.
12. Rang M. The Story of Orthopaedics. Philadelphia, Pa. WB Saunders Co;2000: 401-6.
13. Graham TJ. Surgical correction of malunited fractures of the distal radius. J Am Acad Orthop Surg. Oct 1997;5(5):270-81. [Medline].
14. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg [Am]. Mar 1994;19(2):325-40. [Medline].
15. Altissimi M, Antenucci R, Fiacca C, Mancini GB. Long-term results of conservative treatment of fractures of the distal radius. Clin Orthop. May 1986;(206):202-10. [Medline].
16. Aro HT, Koivunen T. Minor axial shortening of the radius affects outcome of Colles'' fracture treatment. J Hand Surg [Am]. May 1991;16(3):392-8. [Medline].
17. Jupiter JB, Masem M. Reconstruction of post-traumatic deformity of the distal radius and ulna. Hand Clin. Aug 1988;4(3):377-90. [Medline].
18. Fernandez DL. Correction of post-traumatic wrist deformity in adults by osteotomy, bone-grafting, and internal fixation. J Bone Joint Surg Am. Oct 1982;64(8):1164-78. [Medline].
19. Solgaard S. Function after distal radius fracture. Acta Orthop Scand. Feb 1988;59(1):39-42. [Medline].
20. Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop. Jul-Aug 1984;(187):26-35. [Medline].
21. Villar RN, Marsh D, Rushton N, Greatorex RA. Three years after Colles'' fracture. A prospective review. J Bone Joint Surg Br. Aug 1987;69(4):635-8. [Medline].
22. Abbaszadegan H, Jonsson U, von Sivers K. Prediction of instability of Colles'' fractures. Acta Orthop Scand. Dec 1989;60(6):646-50. [Medline].