3. INTRO
Most common orthopaedic injury with a bimodal distribution
o younger patients - high energy, intra-articular
o older patients - low energy / falls, extra-articular,
metaphyseal
50% intra-articular
Associated injuries
o DRUJ injuries must be evaluated
o radial styloid fx - indication of higher energy
Osteoporosis
o high incidence of distal radius fractures in women >50
o distal radius fractures are a predictor of subsequent
fractures
4. Anatomy
scaphoid and lunate
fossa: Ridge normally exists
between these two
sigmoid notch: second
important articular surface
triangular
fibrocartilage
complex(TFCC): distal
edge of radius to base of
ulnar styloid
9. FRYKMAN (joint involvement pattern)
Extra-
articular
Radio-carpal
joint
Radio-ulnar joint
Both joints
{
Same pattern as
odd numbers,
except ulnar
styloid also
fractured
10. FERNANDEZ ( mechanism)
BENDING-metaphysis fails
under tensile stress (Colles,
Smith), Includes DRUJ injury
SHEARING-fractures of
articular surface (Barton, radial
styloid)
11. FERNANDEZ (cont)
COMPRESSION-
intraarticular fracture
with impaction of
subchondral and
metaphyseal bone (die-
punch)
AVULSION-fractures of
ligament attachments (ulna,
radial styloid), radiocarpal
dislocation
COMBINED/COMPLEX-
high velocity injuries
12. MELONE (lunate impaction injury-
intraarticular)
Type I: Stable, without commination
Type II: Unstable “die punch” dorsal or volar
Type IIA: Reducible
Type IIB: Irreducible (central impaction fracture)
Type III: “Spike” fracture. Unstable.
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
15. Universal classification
A) Extraarticular farcture
Type 1-undispced and stable
Type2-dispalced
a)Reducible and staleb
b)reducible and unstable
c)irreducible
B) Intraarticular fracture
Type1-undisplaced and stable
Type 2-Displaced
a)Reducible and stable
b)Reducible and unstable
c)irreducible
d)complex
16. TYPES OF FRACTURES -EPONYMS
Die-punch
fxs
A depressed fracture of the lunate fossa of
the articular surface of the distal radius
Barton's fx Fx dislocation of radiocarpal joint with intra-
articular fx involving the volar or dorsal lip
(volar Barton or dorsal Barton fx)
Chauffer's
fx
Radial styloid fx
Colles' fx Low energy, dorsally displaced, extra-articular
fx
Smith's fx Low energy, volar displaced, extra-articular fx
17. COLLE’S FRACTURE
Most frequently encountered injury to the
distal forearm in older people.
Fall on the outstretched hand with forearm
pronated, wrist in dorsiflexion/extension
injury
Age usually above 50y; F>M.
Extraarticular 2-3 cm away from articular
surface of radius (CORTICO-
CANCELLOUS JUNCTION).
(Combination of dorsal angulation , dorsal
displacement, radial shift and radial
shortening)
Associated # of ulnar styloid.
DINNER FORK
DEFORMITY
18.
19. SMITH’S FRACTURE – REVERSE COLLE’S
Fracture of the distal radius with volar
displacement and angulation of the distal
fragment
Flexion injury or a direct blow to the dorsum
of the hand/ fall on back of hand.
Garden-spade deformity
Modified Thomas Classification of Smith's
Fracture:
Type I: Extraarticular
Type II: Crosses into the dorsal articular
surface
Type III: Enters the radiocarpal joint (equivalent
to volar barton fracture dislocation)
20. Fracture dislocation of radiocarpal joint with intra-articular fracures
involving the volar or dorsal lip
Dorsal Barton fracture Volar Bartons fracture
BARTON’S FRACTURE
21. CHAUFFEUR’S FRACTURE
• Involves the lateral margin of the
distal radius, extending through the
radial styloid process into the
radiocarpal articulation .
• Best seen in PA view
22. RADIOGRAPHIC PARAMETERS
View Measurement Normal Acceptable criteria
AP Radial height 13 mm <5 mm shortening
Radial inclination 23 degrees change <5°
Articular step off congruous <2 mm step off
LAT Volar tilt 11 degrees
dorsal angulation
<5° or within 20° of
contralateral distal
radius
26. MANAGEMENT AIMS
Efficient and functional wrist
Accuracy of articular reduction (to reduce degeneration)
Restoration of anatomy
Radial alignment and length (joint stability)
Early motion of wrist and fingers
Promote bone healing
Avoid complications
27. MANAGEMENT OPTIONS
Conervative:
Closed reduction and immobilization with cast
Operative:
Closed reduction and Percutaneous pinning (CRPP)
External fixation (EF) , spanning/nonspanning
ORIF with plate fixation
dorsal /volar
Arthroscopically assisted reduction and Ex. Fixation of intraarticular fracture.
Bone grafting
In malunion, corrective bone osteotomy
Rehab and follow up:
Subjective assessment tools ,PRWE, DASH.
28.
29. Closed Reduction and cast
Low-energy fracture
Low-demand patient
Medical co-morbidities
Minimal displacement- acceptable
alignment
most extra-articular fxs
repeat closed reductions have 50%
less than satisfactory results
30. After-treatment
Watch for median nerve symptoms
parasthesias common but should diminish over few hours
If persist release pressure on cast, take wrist out of
flexion
Acute carpal tunnel: symptoms progress; Release required
Follow-up x-rays needed in 1-2 weeks to evaluate reduction.
Short-arm cast after 2-3 weeks, continue until fracture healing.
Redisplacement:
Repeat reduction and casting – high rate of failure
Repeat reduction and percutaneous pinning, External Fixation
Or ORIF
31. OPERATIVE INDICATIONS
Surgical fixation (CRPP, External Fixation, ORIF)
radiographic findings indicating instability (pre-reduction radiographs
best predictor of stability)
displaced intra-articular fx, Step-off
volar or dorsal comminution
DRUJ Incongruity
Open and high energy fractures
Associated neurovascular injury/tendon injury
severe osteoporosis
dorsal angulation >5° or >20° of contralateral distal radius
>5mm radial shortening
Failed closed reduction and casting
associated ulnar styloid fractures do not require fixation
32. CRPP (CLOSED REDUCTION &
PERCUTANEOUS PINNING)
Indications
can maintain sagittal length/alignment in extra-articular fxs with
stable volar cortex
cannot maintain length/alignment when unstable or comminuted volar
cortex
Techniques
Kapandji intrafocal technique
In conjunction with external fixation (Augmented external
fixation)
Rayhack technique with arthroscopically assisted reduction
Outcomes
82-90% good results if used appropriately
33.
34. Complications
Mal-union ( may needs augmentation with additional casting)
Pin track infection
RSD
Finger stiffness
Loss of reduction more common than plating
Tendon rupture
nerve injury
35. External Fixation
1. Spanning, 2. Nonspanning Indications
alone cannot reliably restore 10 degree palmar tilt
therefore usually combined with percutaneous pinning technique or plate fixation
Technical considerations
relies on ligamentotaxis to maintain reduction
place radial shaft pins under direct visualization to avoid injury to superficial radialnerve
nonspanning ex-fix can be useful if large articular fragment
avoid overdistraction (carpal distraction < 5mm in neutral position) and excessive volar flexion and ulnar
deviation
limit duration to 8 weeks and perform aggressive OT to maintain digital ROM Outcomes
important adjunct with 80-90% good/excellent results
Complications
stiffness and decreased grip strength
pin complications (infections, fx through pin site, skin difficulties)
neurologic (iatrogenic injury to radial sensory nerve, median neuropathy, RSD)
36. Spanning ( Ligamentotaxis)
A spanning fixator isone
which fixes distal radius
fractures by spanning the
carpus; I.e., fixation into
radius and metacarpals
40. VOLAR PLATING
volar plating preferred over dorsal plating
volar plating associated with irritation of both
flexor and extensor tendons
rupture of FPLis most common withvolar
plates
associated with plate placement distal to
watershed area, the most volar margin of the
radius closest to the flexor tendons
new volar locking plates offer improved
support to subchondral bone
41. DORSAL PLATING
dorsal plating historically associated with extensor tendon irritation and
rupture
dorsal approach indicated for displaced intra-articular distal radius fracture
with dorsal comminution
can combine with external fixation
bone grafting if complex and comminuted
studies showed improved results with arthroscopically assisted reduction
volar lunate facet fragments may require fragment specific fixation to
prevent early post-operative failure
42. Universal classification based Options
TYPE TREATMENT
1)Non articular undisplaced Cast/splint
2)Non articular displaced Close reduction and cast application
Percutaneous pin fixation/external fixation
3)Articular undisplaced Cast/percutaneous pin fixation
4)Articular displaced
A)Reducible,stable
Cast/percutaneous fixation/external fixation
B)Reducible,unstable
External fixation/ex fix with percutaneous pin
fixation
C)Irreducible
ORIFwith plate
External fixation
Combined external and internal fixation
43. Complications
Unsightly scar
Tendon rupture (flexor or extensor)
Some patients may require implant removal Implant cost
Technically more difficult Median nerve neuropathy
(CTS)
most frequent neurologic complication
1-12% in low energy fxs and 30% in high energy fxs
prevent by avoiding immobilization in excessive wrist flexion
treat with acute carpal tunnel release for:
progressive paresthesias
paresthesias do not respond to reduction and last > 24-48 hours
44. Ulnar nerve neuropathy
seen with DRUJ injuries
EPLrupture
nondisplaced distal radial fractures have a higher rate of spontaneous rupture
of the extensor pollicis longus tendon
extensor mechanism is felt to impinge on the tendon following a nondisplaced
fracture and causes either a mechanical attrition of the tendon or a local area
of ischemia in the tendon.
treat with transfer of extensor indicis proprius to EPL
Radiocarpal arthrosis (2-30%)
90% young adults will develop symptomatic arthrosis if articular stepoff > 1-2
mm
may be nonsymptomatic
45. Malunion and Nonunion
Intra-articular malunion
treat with revision at > 6weeks
Extra-articular angulation malunion
treat with opening wedge osteotomy with ORIFand bone grafting
Radial shortening malunion
radial shortening associated with greatest loss of wrist function and degenerative changes in extra-articular fxs
treat with ulnar shortening
ECU or EDM entrapment
entrapment in DRUJinjury
Compartment syndrome
RSD/ CRPS
46. BMC Musculoskelet Disord. 2013; 14: 170.
Published online 2013 May 22. doi: 10.1186/1471-2474-14-170
PMCID: PMC3665633
Early prognostic factors in distal radius fractures in a younger than
osteoporotic age group: a multivariate analysis of trauma radiographs
Annechien Beumer, Tommy R Lindau, and Catharina Adlercreutz
CONCLUSION:
The present study showed that post-traumatic ulna fracturesare the most
important factor in predicting bad outcome in non-osteoporotic patients, but
that
especially intra-articular fractures and to a lesser extent dorsal tilt may be of
importance too.
47. JHand Surg Am. 2013 Aug;38(8):1469-76. doi: 10.1016/j.jhsa.2013.04.039.
Volar locking plates versus external fixation and adjuvant pin fixation in
unstable distal radius fractures: a randomized, controlled study.
Williksen JH1, Frihagen F,Hellund JC,Kvernmo HD, Husby T.
CONCLUSIONS:
Although we did not find a significant difference between the groups for the
QuickDASH score, we believe that our results support the use of VLPs for the
treatment of unstable distal radius fractures. A serious concern is that some
patients will have to have their plates removed; therefore, improving the
surgical technique is important.
48.
49. CASE 1- DISTAL RADIUS FRACTURE
31 YEARS OLD SERVING ARMY SOLDIER
TRANSFFERED TO 5AFH FROM 162 MH
,HISTORY OF FALL ON OUTSTRECHED HAND
LEADING DEFORMITY TO RIGHT WRIST.
ON EXAMINATION:
PAINFULL ROM
DEFORMITY
SWELLING
NO DNVD
55. CASE 2- COMMINUTED DISTAL RADIUS
FRACTURE
34 YEARS OLD SERVING AIR WARRIOR
TRANSFFERED TO 5AFH FROM 22WG ,
SUSTAINING INJURY TO HIS RIGHT WRIST.
ON EXAMINATION:
CREPITUS
RESTRICTED ROM
DEFORMITY
SWELLING
NO DNVD
56.
57.
58. CASE 3- COMMINUTED DISTAL RADIUS
FRACTURE
68 YEARS OLD WIFE OF RETD AIR WARRIOR,
SUSTAINING INJURY TO HIS RIGHT WRIST.
ON EXAMINATION:
CREPITUS
RESTRICTED ROM
GROSS DEFORMITY
SWELLING ++
NO DNVD
59.
60.
61. CASE 4- INTRA-ARTICULAR DISTAL RADIUS
FRACTURE WITH DRUJ DISLOCATION
46 YEARS OLD SERVING ARMY OFFICER,
SUSTAINING INJURY TO HIS RIGHT WRIST
DUE TO FALL ON BACK OF HAND WHILE
RUNNING.
ON EXAMINATION:
PIANO SIGN +
CREPITUS
RESTRICTED ROM
GROSS DEFORMITY
SWELLING ++
NO DNVD
