Fractures of distal end radius

FRACTURES OF DISTAL END RADIUS

Dr. MAHAK JAIN

HISTORY• First surgeon to recognize these injuries was Pouteau in 1783,

although his work was not widely publicized.• Later Abraham Colles in 1814 gave the classic description of this

fracture.• Dupuytren brought attention that this is a fracture rather than a

dislocation as it was previously assumed.• Barton in 1838 described wrist subluxation consequent to intra-

articular fractures of distal radius which could be dorsal or volar.• Smith described fracture of distal radius with forward displacement.

INTRODUCTION• Distal radius fractures occur through the distal metaphysis of the

radius.• It may involve the articular surface frequently involving the ulnar

styloid.• Most commonly results from a fall on the outstretched hand

1. Forced extension of the carpus2. Impact loading of the distal radius

• Fractures of distal end radius are classified on the basis of :

1. Presence or absence of intra-articular involvement

2. Degree of comminution

3. Dorsal or volar displacement

4. Involvement of distal radio-ulnar joint

INCIDENCE• Fractures of the distal end radius represent approximately 16% of all

fractures treated by orthopaedic surgeons.• There are three main peaks of fracture incidence :

1. Children aged 5-14 years2. Males under 50 years (high velocity)3. Females over 40 years of age (low velocity)

• Elderly – most commonly extra-articular• Young – most commonly intra-articular• Most common risk factors for elderly patients are decreased bone

mineral density, female gender & early menopause.

ANATOMY• 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 and three articular facets (scaphoid, lunate and sigmoid notch). Distal radius fuses with diaphysis at 17 years of age in females and 19 years in male.• The metaphysis is flared distally in both the AP

and the lateral planes with thinner cortical bone lying dorsally and radially . The significance of the thinness of these cortices is that the fractures typically collapse dorso-radially.

• 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 stout radiolunate ligament. Displacement of this fragment is associated with palmar displacement of the carpus and also with loss of forearm rotation.

• 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, which articulates with the convex head of the distal ulna. The origin of TFCC attaches to the distal border of sigmoid fossa.

• TFCC is the main stabilizer of distal radioulnar joint in addition to contributing to ulnocarpal stability.

• The dorsal aspect of the distal radius is narrower than the volar aspect.

• The most prominent ‘V’ shaped crest on the dorsal aspect is called lister’s tubercle.

• In axial loading, radius bears 80% of the load and ulna bears 20% of the load.

LIGAMENTOUS ANATOMY• Extrinsic ligaments around the distal end radius play an important role in

closed reduction of the fractures (Ligamentotaxis).• The palmar extrinsic ligaments are attached to the distal radius, and it is

these ligaments that are relied on to reduce the components of a fracture using closed methods.

Applied anatomy• Jacob and his co-authors interpreted the wrist as consisting of

three distinct columns, each of which is subjected to different forces and thus must be addressed as discrete elements

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

The 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

The medial column

The ulnar column consists of the ulna styloid but also should include the TFCC and the ulnocarpal ligaments

DIAGNOSIS• There is usually a history of fall on out-stretched hand.• Wrist is typically swollen with ecchymosis and is tender.• Visible deformity of the wrist with hand most commonly displaced in

dorsal direction.• Adequate and accurate assessment of the neurovascular status of the

hand is performed before any treatment is given out.• Radiograph of the wrist are taken in AP, Lateral & Oblique views.• CT scan of wrist can be done to see the extent of intra-articular

involvement & communition.

SOME IMPORTANT MEASUREMENTS• Distal radio-ulnar joint congruity can be seen by the following

measurements-

1. Palmar tilt – normal range is 11 to 12 degrees2. Radial inclination – normal range is 20 to 23 degrees3. Ulnar variance – normal range is 0 to -2mm4. Radial length – normal range is 10 to 12 mm5. Carpal mal-alignment

1) Volar / Palmar Tilt • On a true lateral view a line is drawn connecting the most distal points of

the volar and dorsal lips of the radius. The volar or palmar tilt is the angle created with a line drawn perpendicular to the longitudinal axis of the radius.

2) Radial Length / Height• Radial length is measured on the AP radiograph as the distance

between one line perpendicular to the long axis of the radius passing through the distal tip of the radial styloid & second line intersects distal articular surface of ulnar head.

3) Ulnar Variance• This is a measure of radial shortening and should not be confused with

measurement of radial length. Ulnar variance is the vertical distance between a line parallel to the medial corner of the articular surface of the radius and a line parallel to the most distal point of the articular surface of the ulnar head, both of which are perpendicular to the long axis of the radius

4)Radial InclinationOn the AP view the radius inclines towards the ulna. This is measured by the angle between a line drawn from the tip of the radial styloid to the medial corner of the articular surface of the radius and a line drawn perpendicular to the long axis of the radius.

5)Carpal MalalignmentOn 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 outwith the carpus

• GREATER THAN 2mm articular step-off• >10 degrees of dorsal tilt• <15 degrees of radial inclination• Loss of radial height > 5mm• Communition of one cortex across midaxial line of lateral xray• Communition of both dorsal palmar cortices• Irreducible fracture• Loss of reduction after attempt to reduce.

INDICATORS OF INSTABILITY

CLASSIFICATION• There is perhaps no other fracture in the orthopaedic literature that

has garnered so many eponyms over time than fractures of the distal radius.• Various eponyms are :

1. Colle’s fracture2. Smith’s fracture3. Barton’s fracture4. Chauffer’s fracture / hutchinsons fracture5. Die punch fracture / lunate load fracture

Colle’s fracture• It is an extra-articular fracture occurs at cortico-cancellous junction of distal end

of radius within 2cm from the articular surface• The distal fragment is usually displaced dorsally.• It may extend into DRUJ with six displacements

ImpactionLateral displacement Lateral rotation (angulation)Dorsal displacementDorsal rotation (angulation)Supination.

It may often accompany fracture of the ulnar styloid which signify avulsion of the TFCC and ulnar collateral ligaments

Smith’s fracture/Reverse colle’s fracture

• Occurs at the same level on the distal

radius as a colles' fracture.

• Distal fragment displaced in palmar (volar)

direction with a "garden spade" deformity. • Smith's fracture typical deformity:1. Dorsal prominence of the distal end of

the proximal fragment2. Fullness of the wrist on the volar side

due to the displaced distal fragment3. Deviation of the hand toward the radial

side

Barton’s fracture• It is an intrarticular fracture dislocation or subluxation

in which the rim of the distal radius dorsally or volarly is displaced with the hand and carpus• There are 2 types Dorsal barton volar barton

Dorsal barton Volar barton

Chauffeur’s fracture/hutchinson fracture• It is an intra-articular fracture involving

the radial styloid, the radius is cleaved in a sagittal plane and the fragment is displaced proximally.• Isolated fracture of the radial styloid

are fairly common from backfiring of starting handle of car

Lunate load/Die punch fracture• It is an intraarticular fracture with displacement of the

medial articular surface which usually represents a depression of dorsal aspect of lunate fossa

• Ideal classification system should describe:• Type of injury• Severity• Evaluation• Treatment•Prognosis

Common Classifications

1. Gartland & Werley2. Frykman (radiocarpal & radioulnar)3. AO4. Melone (impaction of lunate)5. Fernandez (mechanism)

Gartland & Werley

1. Simple Colles fracture without intrarticular involvement2. Comminuted Colles' fractures with intra-articular extension without displacement3. Comminuted Colles' fractures with intra-articular extension with displacement4. Extra-articular, undisplaced

Frykman’s ClassificationExtra-articular

Radio-carpal joint

Radio-ulnar joint

Both joints

{Same pattern as odd numbers, except ulnar styloid also fractured

Importance of sigmoid notch articular surface

Melone’s classificationType I: Stable fracture without displacement. This

pattern has characteristic fragments of the radial styloid and a palmar and dorsal lunate facet.

Type II: Unstable “die punch” with displacement of the characteristic fragments and comminution of the anterior and posterior cortices• Type IIA: Reducible• Type IIB: Irreducible (central impaction

fracture)

Type III: “Spike” fracture. Unstable. Displacement of the articular surface and also of the proximal spike of the radius

Type IV: “Split” fracture. Unstable medial complex that is severely comminuted with separation and or rotation of the distal and palmar fragments

Type V: Explosion injury

effect of the impaction of the lunate on the radial articular surface to create four characteristic fracture fragments

AO/ OTA Classification

Classification – Fernandez (1997)1. Bending- metaphysis fails under

tensile stress (Colles, Smith) Extra-articular

2. Shearing- fractures of joint surface Intra articular (Barton, radial styloid)

3. Compression - intraarticular fracture with impaction of subchondral and metaphyseal bone (die-punch)

Complex articular fracture & radial pilon fracture

4. Avulsion- fractures of ligament attachments (ulna, radial styloid)

5. Combined complex - high velocity injuries

Preserve hand and wrist function

Realign normal osseous anatomy promote bony healing

Avoid complications

Allow early finger and elbow ROM

Goals of treatment

RATIONALE FOR TREATMENTThe goal of treatment of these fractures is a wrist that provides sufficient pain-free motion and stability to permit vocational and daily activities in all age groups without the propensity for future degenerative changes in the young

Options for Treatment1. Casting2. External Fixation• Joint-spanning• Non bridging

3. Percutaneous pinning4. Internal Fixation• Dorsal plating• Volar plating• Combined dorsal/volar plating• focal (fracture specific) plating

Indications for Closed Treatment

Low-energy fractureLow-demand patientMedical co-morbiditiesMinimal displacement- acceptable

alignment

Technique of Closed Reduction

Anesthesia (pain relief & decrease muscle spasm)• Hematoma block• Intravenous sedation• Bier block

Traction: finger traps and weights or manual tractionReduction Maneuver (dorsally angulated fracture):

• hyperextension of the distal fragment, • Correct radial tilt• Maintain weighted traction and reduce the distal to the proximal fragment with

pressure applied to the distal radius.

Apply well-molded splint or cast, with wrist in neutral to slight flexion.Do check X-ray to confirm the acceptable reduction.

Post reduction management1. Take x-ray immedaitely after the application of the cast.

If reduction is not satisfactory, another attempt to acheive accurate reduction should be made.

2. If there is any circulatory embarrassment, split the cast along the dorsum of its entire length.

3. Elevate the arm with the fingers pointing towards the ceiling for the first 48 hrs.

4. Take x ray again on the 5th and 10th days ,check for maintanance of position.

5. Institute physical therapy, heat, gentle massage, water massage and active exercises for the fingers, elbow and shoulder.

• Exercise programme:1) Maximum extension of all digits2) Opposition of the thumb3) The grasp or fist exercise with all finger flexing to the

palmar creases or as near as possible to it4) The claw exercise with the MCP joint of the fingers kept

extended but the IP joint maximally flexed5) The table top exercise with the MCP joint maximally

flexed but the IP joint extended6) Abduction and adduction of all fingers7) Plus use shoulder and elbow is a must

Complications • Failure or loss of reduction• Skin complications• Tendon adhesions and entrapement• Carpal tunnel syndrome due to excessive palmar flexion• Nerve complications• Vascular injury

Indications for Surgical Treatment

1. High-energy injury with instability2. Comminuted displaced intraarticular fracture3. Open injury4. Radial inclination < 15°5. Articular step-off, or gap > 2mm6. Dorsal tilt > 10 °7. DRUJ incongruity8. Failed closed reduction

1.Percutaneous direct pinning• Aim of this procedure is to fix the mobile fragment to the

opposite cortex proximal to the fracture• Direct pinning of the fragments especially the

intermediate column through the distal ulna add stability to the DRUJ and medial half of articular surrface• Application is extrafocal where entry point of k wire is

away from fracture site mainly 2 types a)transulnar b)transradial• Indications-a)nonarticular displaced b)articular

nondisplaced c)articular displaced,all of which are reducible and stable after reduction• Contraindications are severe osteoporosis,severe

communition,soft tissue interruption and chauffer fracture

AFTERTREATMENT The arm is immobilized in a cast below the elbow with the forearm and wrist in neutral position. The Kirschner wires that have been cut off just beneath the skin are removed at 6 weeks. The wrist is supported with a removable static splint, and gradual range-of-motion exercises are permitted

2.Kapandji technique of intrafocal pinning with pins for nonarticular fracture

• In intrafocal pinning a smooth k-wire is inserted after a manual reduction,through a short skin incision,directly into the fracture line• Secondary displacement is made impossible by

immediate contact of the distal fragment with the arum nut of the pins which are working as an abutement,not as a resistant component

Kapandji technique of “double intrafocal wire fixation” to reduce and maintain distal radial fractures. A 0.045- or 0.0625-inch Kirschner wire is introduced into the fracture in a radial to ulnar direction. When the wire reaches the ulnar cortex of the radius, it is used to elevate the radial fragment and recreate the radial inclination. This wire is then introduced into the proximal ulnar cortex of the radius for stability. A second wire is introduced at 90 degrees to the first in a similar manner to restore and maintain volar tilt.

3.External fixation

• Two types of external fixation1) Spanning external fixation2) Non-spanning external fixation

Spanning (Ligamentotaxis)•A spanning fixator is one which fixes distal radius fractures by spanning the carpus; I.e., fixation into radius and metacarpals•Bridging external fixation allows distraction across the radiocarpal joint and directly neutralizes axial load.•Ligamentotaxis of the fracture fragments•Adjunctive fixation and supplemental bone grafting results in earlier union.

Addition of percutaneous pinning improve the stability of external fixation and prevent loss of reduction

full finger motion

Non-spanning

• 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.•Indication : extra-articular or minimal intra-articular dorsally displaced fractures with metaphyseal instability •Contraindication : lack of space for pins in the distal fragment. 1 cm of intact volar cortex required for purchase of pins

Limited indications

But shows good results

Early ROM permitted

Complications Complication rates are high•Pin tract infection•RSD Finger stiffness• Loss of reduction; early vs. late• Tendon rupture

Open Reduction and Internal Fixation

Open reduction of articular fractures of the distal radius is indicated in active patients with good bone quality when anatomic restoration of the joint surface cannot be achieved by closed manipulation, ligamentotaxis, or percutaneous reduction maneuvers or as an alternative to percutaneous fixation at the preference of the patient or surgeon.

Dorsal plating• Internal fixation using a dorsal plate has several

theoretical advantages. • Technically familiar to most surgeons, the approach

avoids the neurovascular structures on the palmar side.• Further, the fixation is on the compression side of most

distal radius fractures and provides a buttress against collapse. • Initial reports of the technique demonstrated successful

outcomes with the theoretical advantages of earlier return of function and better restoration of radial anatomy than was seen with external fixation.

•However, there were increasing reports of extensor tendon ruptures because of prominent hardware, particularly at Lister tubercle. •The more distally the plate is applied on the dorsum of the wrist, the more proximally the distal screws need to be directed to avoid articular penetration. •This oblique orientation of the screws allows the distal fragment to displace palmarly. •The palmar displacement of the fragment is particularly problematic because it results in (1) incongruity at the distal radioulnar joint and (2) prominence of the hardware dorsally with the

tendency for extensor tenosynovitis or tendon rupture

Operative Technique• A longitudinal incision is centered over the fracture in line with the ulnar aspect of

Lister tubercle. • The extensor retinaculum is incised in a z-plasty manner that allows for one limb to

be placed over the plate and the second limb to be repaired over the extensor tendons to prevent bow-stringing of the tendons with wrist extension.

• The extensor pollicis longus tendon is dislocated from its position at the tubercle and subperiosteal dissection is performed radially and ulnarly.

• Care should be taken to preserve all of the dorsal fragments for re-establishment of radial length.

• Traction is then applied by either an assistant or by the use of finger traps with weights suspended off the end of the table.

• Care should be taken to ensure that the hand is not pronated relative to the forearm.

Complications Because of direct contact with the dorsal plate• Irritation• Synovitis• Attrition• Tendon rupture

Volar Plate FixationRegardless of the displacement of the distal fragment (dorsal, volar, radial), volar plating of both articular and nonarticular fractures is an effective fixation method that may reduce some of the soft tissue complications associated with dorsal plating. Advantages of palmar exposure and volar plating include the following

Operative technique• Palmar plates may be applied through either a flexor carpi radialis

(FCR)/radial artery interval or through a midline flexor tendon/ulnar neurovascular bundle interval. The FCR/radial artery approach is preferable for (1) fixation of dorsally displaced fractures with dorsal comminution and (2) fixation of partial articular fractures (articular shear fractures). The skin incision is centered over the FCR, with care being taken to avoid injury to the palmar cutaneous branch of the median nerve that lies ulnar to the tendon. The radial artery is mobilized, and dissection is carried radially by releasing the brachioradialis tendon from the radial styloid.

The second surgical approach to the palmar radius is the flexor tendon/ulnar neurovascular bundle interval. The skin incision is centered over the ulnar border of the palmaris longus, the flexor tendons are mobilized radially, and the ulnar neurovascular bundle is taken ulnarly. With this approach the pronator quadratus is released from the ulna. The incision may be extended distally to release the transverse carpal ligament, particularly if the patient had any median nerve symptoms preoperatively. This incision is preferred when the majority of the comminution is at the palmar lunate facet.

• Minimal volar comminution facilitates reduction of dorsally displaced fractures.

• Anatomic reduction of the volar cortex facilitates restoration of radial length, inclination, and volar tilt.

• Avoidance of additional dorsal dissection helps preserve the vascular supply of comminuted dorsal fragments

• Because the volar compartment of the wrist has a greater cross-sectional space and the implant is separated from the flexor tendons by the pronator quadratus, the incidence of flexor tendon complications is lessened.

• The use of fixed-angle volar plate designs avoids screw “toggling” in the distal fragment and thus reduces the danger of secondary displacement

• When stabilized with a fixed-angle internal fixation device that uses subchondral pegs or screws, control of shortening and late displacement of articular fragments are improved and the need for bone grafting reduced

ADVANTAGES

Complications• Locking plates is the potential for articular penetration

with distal plate position on the palmar surface of the radius• Collapse of the fracture also can lead to joint penetration

by the distal screws especially in osteopenic patients• Extensor tendon problems can be caused by penetration

Complications of Distal radius fractures 1) Chronic Regional Pain Syndrome

2) Nonunion• Nonunion of distal radius fractures is rare but presents unique

treatment challenges because of the associated pain, joint contractures, tendon imbalance or rupture, and occasional severe bony deformity

• nonunion of ulnar styloid process fractures in conjunction with distal radius fractures is quite common and yet is rarely symptomatic

• Treatment of distal radius nonunion must be individualized and based on the patient's symptoms, functional deficit, and bony substance

3) Mal-union4) Nerve Injuries5) Tendon rupture6) Loss of range of motion

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