Distal Radius Fractures

directly from : https://coreem.net/core/distal-radius-fractures/ written by – Mark Mikhly, MD

Definition: Fracture at the metaphysis or the articulation of the distal radius

Mechanism: Most common mechanism is a fall on an outstretched wrist that is dorsiflexed

Epidemiology

• One of the most common fractures seen in the ED. >650,000 annually
• Represent 1/6^th of all fractures treated in Emergency Departments
• Increased incidence with age; women at higher risk then men

Physical Exam

• Variable gross wrist deformity with displacement of the hand in dorsal or volar relation to the wrist, dependent on the fracture pattern.
• Neurovascular assessment of the hand
  • Critical to perform complete neurologic exam
  • Median nerve injury common
    • Thenar paralysis (Ape hand deformity): Inability to oppose or abduct thumb
    • Sensory loss of palmar aspect of first, second, third, and radial half of fourth fingers
• Carpal tunnel compression syndromes are common (13-23%).
• A full examination of the ipsilateral elbow and shoulder is required to assess for injuries caused by translated force

Colles’ Fracture (studyblue.com)

Fracture Classification

• Descriptive Classifications
  • Open vs Closed
  • Displacement
  • Angulation
  • Comminution
  • Loss of length
• Eponyms
  • Colles’ (or “dinner fork” deformity):
    • 90% of distal Radius fractures
    • Extra-articular, dorsally angulated distal radius
    • Caused by fall onto hyperextended, radially deviated wrist
    • Eponym traditionally only included non-articular fractures. Currently accepted to describe intra-articular fractures
  • 
  • Common Distal Radius Fractures (fprmed.com)Smith (“reverse Colles’” or “garden spade” deformity):
    • Distal volar displacement or angulation of fracture
    • Often caused by fall onto dorsiflexed, supinated wrist
    • Typically unstable and require open reduction and internal fixation (ORIF)
  • Barton
    • Intraarticular  dorsal or volar (more frequent) rim fracture
    • Extreme dorsiflexion of pronated wrist
    • Usually unstable and not easily reducible. Requires ORIF
  • Chauffer/Hutchinson:
    • Radial styloid avulsion fracture
    • Dorsiflexion and ulnar deviation causing compression of scaphoid against styloid
    • Associated w/ intercarpal ligamentous injury
    • Sugar tong splint with urgent orthopedic evaluation for likely ORIF
  • Die Cast
    • Depressed fracture of articular surface at the lunate fossa
    • Easy to miss because the carpal arc is not disrupted
    • Requires urgent orthopedic follow up for likely ORIF
  • Buckle injury
    • Buckle injuries are often subtle radiographically
    • No reduction required
    • Below-elbow fibreglass/plaster backslab or removable wrist splint for 3 weeks

X-Ray Fracture Patterns:

Lateral and AP x-ray of a five year old who sustained a buckle injury of the distal radius.
They are best viewed on the lateral x-ray. Bilateral or unicortical cortical bulging can occur.

X-ray Findings

• Necessary views: AP, Lateral and Oblique
• Review films for concomitant injuries, particularly carpal bone injuries which can easily be overlooked
• Key Measurements:

	Normal Range	Acceptable in Healed Wrist
a) Radial Inclination/Tilt:Measured on PA view by drawing a line perpendicular to the long axis of the radius and a tangential line from the radial styloid to the ulnar corner of the lunate fossa.	13-30 degrees.	< 5 degree loss
b) Radial Length/Shortening:Measured on PA view by measuring the distance from the tip of the radial styloid to the distal articular surface of the ulna.	8-18 mm	< 5 mm Radial shortening
c) Volar Tilt:Measured on Lateral view by drawing a line perpindicular to the long axis of the radius and a tangential line along the slope of the dorsal to volar surface of the radius	0-28 degrees, avg of 11 degrees	Dorsal angulation of <5mm or within 20 degrees of contralateral wrist

Hematoma Block (EM News)

ED Management

• Closed Reduction
  • All closed fractures should undergo closed reduction even if operative management is expected
    • Reduces swelling
    • Relieves nerve compression
    • Provides pain relief
  • Always target optimal fracture reduction
    • Closed reduction may be definitive management for non-displaced or minimally displaced fractures (ie. those fractures with acceptable healing parameters or those that can be reduced to those parameters)
    • Closed reduction in high risk surgical patients may be definitive, even outside “acceptable” parameters
• Reduction technique
  • Supply adequate analgesia
    • Hematoma block
    • Systemic analgesia
    • Procedural sedation if necessary
  • Place Patient in traction with finger traps and hanging weights
  • Hyperextension –> Traction –> Reduction

• For further guidance on reduction technique refer to the following video: https://www.youtube.com/watch?v=EhJ7kpurKnk

• Place patient in a
  • Sugar Tong Splint w/ wrist in Neutral Position and MCP joints free OR
  • Charnley Slab – partial ‘backslab’ plaster envelops the distal radius dorsal, lateral and volar surfaces
• Repeat neurovascular exam after reduction and splinting
• Close Orthopedic follow up for repeat imaging and decision for operative management

Complications of a distal radius fracture 

• Median nerve injury either acutely or by delayed development of Carpal Tunnel Syndrome.
• Vascular injury
• Malunion
• Manipulation failure, either acutely or late by fracture slip (often as the swelling subsides but also as the fracture site remodels)
• Extensor Pollicis Longus (EPL) tendon rupture: painless, around the time the cast comes off in my experience.
• Osteoarthritis
• Chronic reduced wrist movement.
• Grip strength reduction

Prognosis

• Colles’ fractures can be managed non-operatively if reduction is within acceptable anatomic limits
• Loss of reduction and need for eventual surgical management is associated with:
  • Higher degrees of initial displacement
  • Elderly patients
  • Metaphyseal comminution
• Potential complications of Colles’ fractures:
  • Median nerve neuropathy, sometimes requiring carpal tunnel release
  • Osteoarthritis at radiocarpal and radioulnar articulations
  • Finger/Wrist/Elbow stiffness –  minimize likelihood with aggressive occupational therapy
  • Extensor pollicis longus tendon rupture as late complication, more frequently post ORIF.
• All distal radius fractures have potential complications that include neuropathies, tendon injuries, and osteoarthritis

Take Home Points

• Every distal radius requires closed reduction and placement of a sugar-tong splint
• Document a thorough neurovascular exam prior to and after reduction with particular attention to the median nerve
• Emphasize early orthopedic surgery follow up for further management
• Don’t miss concomitant hand, wrist, forearm and elbow injuries such as lunate dislocation, carpal fractures, or radial head dislocation.

Read More

Radiopaedia: Distal Radial Fracture

Radiopaedia: Chauffer Fracture

Orthofilms: Closed Reduction of a Distal Radius Fracture

DeAngelis MA, Wald DA. Wrist. In: Sherman SC. eds. Simon’s Emergency Orthopedics, 7e. New York, NY: McGraw-Hill; 2014. Link

Egol K et al. Handbook of Fractures. Philadelphia: Wolters Kluwer; 2015: 266-278

Petron, DJ. Distal Radius Fractures in Adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on June 8^th, 2016)