For education of orthopaedics

1. Distal Radial Fractures;
Management Principles
Maj; Ye Win Kyi
DSOH
AO Principle of Fracture Fixation Basic Course

2. Learning objectives
• Describe different types of distal radial fractures
• List indication for operative and nonoperative treatment
• Outline surgical approaches for the fixation of distal radial
fractures
• Choose appropriate implants according to fracture type

3. Distal radial fractures—the problem
• Most common fracture of all ages
• Many different injuries
• A spectrum from simple to complex
• High energy
• Younger
population
• Shortening and
collapse
• Carpal
instability
• Minimally
displaced
• Extraarticular
fractures
• Impacted stable
fractures
• Low energy
• Poor bone stock
• Elderly population

4. Distal radial fractures—the problem
• Multiple treatment options
• Typically poor literature
• American Academy of Orthopaedic Surgery’s (AAOS) Clinical
Practice Guideline Summary:
29 recommendations—5 moderate; 7 weak; 14 inconclusive
• Leads to controversy

5. Anatomy—complex
• Dorsal cortex:
• Thinner, weaker
• Volar cortex:
• Origin of radiocarpal ligaments
• Scaphoid fossa
• Lunate fossa
• Sigmoid notch

6. Normal values—palmar tilt
11 degrees
11°

7. Normal values—radial length
11–12 mm

8. Normal values—radial inclination
23°

9. Normal values—ulnar variance
0 mm

10. Changes in wrist mechanics may lead to arthrosis
especially with intraarticular steps

11. AO/OTA Fracture and Dislocation Classification
A: Extraarticular 2R3A
(within width of joint)
B: Partial articular 2R3B
C: Complete articular 2R3C

12. Type A
Extraarticular
2R3A AA
Type B
Partial articular
2R3B
)
Type C
Complete articular
2R3C
A1 Extraarticular A2 Tranverse, dorsal or volar A3 Wedge intact, fragmentary
multifragmentary
B1 Sagittal B2 Dorsal rim fractures B3 Volar rim fractures
C1 Simple articular and
metaphyseal, saggital and
coronal
C2 Simple articular
metaphyseal multifragmentary
sagital, coronal and extending
to diaphysis
C3 Multifragmentory articular,
simple or multifragmentory
metaphyseal

13. Who needs surgery?
Most distal radial fractures do NOT need an operation:
• Nondisplaced fractures
• Very low-demand patients
• Geriatric patients

14. Who needs surgery?—absolute indications for surgery
Some distal radial fractures must have an operation:
• Open fracture
• Acute carpal tunnel syndrome

15. Who needs surgery?—relative indications
• Failure of closed reduction
• Failure to adequately reduce the fracture
• Difficult to treat the patient with a cast

16. What is an adequate reduction?
• Intraarticular step-off: < 2 mm
• Radial shortening: < 3 mm
• Dorsal tilt: < 10° dorsal
• Radial inclination: > 15°
• Distal radioulnar joint (DRUJ) incongruity: < 1–2 mm

17. Treatment options
• Closed reduction and application of cast
• Closed reduction, insertion of percutaneous pins, and
application of cast
• Closed reduction and application of external fixator
• Open reduction and application of plate
• Combination of methods

18. Operative treatment of distal radial fractures—
decision making
• Evaluate patient’s functional
demand
• Do a neurological exam
(median nerve?)
• Traction film?

19. Intraarticular fractures need computed tomographic (CT) evaluation
Decision making—understand the fracture

20. Closed reduction and cast
• Undisplaced or minimally displaced fractures
• Most children's fractures
• Extraarticular fractures in elderly that can be reduced

21. Closed reduction and cast—BEWARE
• Bad cast
• Loss of reduction

22. AAOS recommendations
• No method of fixation can be recommended over another
• “There is no Level-I clinical evidence suggesting a superior
modality for treatment of distal radial fractures.”

23. Percutaneous pins
• Fracture reduced with closed means
• A types
• B1 radial styloid

24. External fixation
• Minimally invasive
• Reduction is achieved by distraction
• Joint often cannot be reconstructed
• Intraarticular “Die Punch" cannot be reduced
• Impossible to initiate early motion

25. External fixation—complications
• Nerve injury
• Pin breakage
• Infection
• Overdistraction
• Stiffness

26. Mini-open approach to avoid damage to radial nerve
Superficial radial nerve

27. Percutaneous pins and external fixation

28. Open reduction and plating
• Goals of treatment:
• Achieve an anatomical reduction of the joint
• Sufficient stability to allow early range of motion (ROM)
• Volar approach is most commonly used even with dorsal
comminution

29. Volar approach

30. A3

33. Need “true” lateral x-ray
• Radial inclination view
• Screws safe
• Reduction

34. Complications
Complications following internal fixation of unstable distal radial
fracture with a palmar locking plate:
• Overall complication rates 20–27%
• Flexor and extensor tendon irritation
• Loss of fixation

35. Distal radial fractures—plating through a dorsal approach
• Default approach is anterior
• Exceptions:
• Need to see in the joint Dorsal
• Dorsal shear Dorsal
• Radial styloid 1st dorsal

37. Move away from dorsal plating
Dorsal plates have a higher incidence of tendon complications
versus volar plates

38. Move away from dorsal plating
Dorsal plates have a higher incidence of tendon complications
versus volar plates

39. Distal radial fractures—fixation by triple fragment
specific plating

40. Functional outcome
• Open reduction and internal fixation (ORIF) versus external fixation
• Cast versus ORIF in elderly
• Open reduction and internal fixation better radiographic outcome,
early range improvement
• Differences in range of motion not sustained

41. Take-home messages
• Important to understand anatomy
• Get more information—traction views? CT scans
• Multiple treatment options—consider the patient’s needs and
your skills
• There is no level-1 evidence to support any treatment modality

42. Take-home messages
• Surgical indications
• Intraarticular step-off: 2 mm
• Radial shortening: > 3 mm
• Dorsal tilt: > 10°
• If you elect to use ORIF, beware of:
• Tendons
• Anterior radiocarpal ligaments
• Check DRUJ!