traction on fingers Surgeon: manipulates distal fragment into position Cast immobilization for 6-8 weeks Follow up X-rays at 2 weeks, 6 weeks Check for maintenance of reduction Gradual mobilization after cast removal Physiotherapy Return to activities in 6-8 weeks Complications: malunion, non- union, reflex sympathetic dystrophy Indications for surgery: - Irreducible fracture - Significant displacement after reduction - Open fracture - Associated injuries of distal radioulnar joint Surgical options: - Percutaneous pinning - External fixation - Open reduction and internal fix

1. DISTAL RADIUS FRACTURE
CASE DISCUSSION

2. CASE : FEMALE 52 YR, FALL ON OUTSTRETCHED HAND
• History : 1 hrPTA falls on her outstretching hand. She has pain and swelling
in her wrist. Her wrist has fork-shape deformities.
• Past History : no underlying disease, no drug allergy
• Physical Examination
• V/S – Stable
• Rt wrist - Fork-shape deformity
- Swelling and tender around wrist
- Stepping was palpable at distal radius
- Limit ROM due to pain
- Motor and sensory are intact

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

5. DIAGNOSIS: HISTORY AND PHYSICAL FINDINGS
• History of mechanism of injury
• A visible deformity of the wrist is usually noted, with the hand most
commonly displaced in the dorsal direction. (90% cases)
• The acute shortening of the radius relative to the ulna may manifest as an
open wound palmarly and ulnarly where the intact ulna buttonholes through
the skin.
• Movement of the hand and wrist are painful.
• Adequate and accurate assessment of the neurovascular status of the hand is
imperative. (Median nerve involvement – Carpal tunnel syndrome)

6. DIAGNOSIS: DIAGNOSTIC TESTS AND EXAMINATION
• Evaluation of the injured joint, and a joint above and below
(ipsilateral elbow & shoulder joint)
• Radiographs of the injured wrist (PA & Lateral)
• Radiographs of other areas, if symptoms warrant.
• CT scan of the distal radius in selected instances.

7. IMAGING
• 1- Posteroanterior (PA)
• 2- lateral
• 3- oblique radiographs: (reveal intra-
articular involvement)
• A- The semisupinated, demonstrates
the dorsal facet of the lunate fossa.
• B- The partially pronated, allows
visualization of the radial styloid.

8. ASSESSMENT OF RADIOLOGICAL
PARAMETERS
• 1- Radial height (PA view)Two
Tangential Lines to the Styloid tip and
distal ulnar surface normal is 11-
13mm
• 2- Ulnar variance (UV) measured on
PA radiograph w/ wrist in neutralThis
image demonstrates ulnar plus
variance.

9. • 3-Radial inclination is measured
onthe PA viewThe normal angle is 15-
25º.

10. • 4-The volar tilt, or palmar inclination, is
measured on the lateral view. Slope of
the dorsal-to-palmar surface of the
radius. The normal angle is 10-25º.

11. TRUE LATERAL

12. PATHOMECHANICS
• Injury depends on the position of the wrist, the magnitude and
direction of force, and the physical properties of the bone.

13. CLASSIFICATION
Ideal system should describe:
• Type of injury
• Severity
• Evaluation
• Treatment
• Prognosis

14. COMMON CLASSIFICATIONS
1. Gartland & Werley
2. Frykman (radiocarpal & radioulnar)
3. AO
4. Melone (impaction of lunate)
5. Fernandez (mechanism)

15. CLASSIFICATION – FERNANDEZ (1997)
I. Bending-metaphysis fails under
tensile stress (Colles, Smith)
• extraarticular
II. Shearing-fractures of joint surface
• Intra articular
(Barton, radial styloid)
importance of mechanism and energy level of injury

16. CLASSIFICATION – FERNANDEZ (1997)
III. Compression - intraarticular fracture with
impaction of subchondral and metaphyseal
bone (die-punch)
• Complex articular fracture & radial pilon
fracture
IV. Avulsion- fractures of ligament
attachments (ulna, radial styloid)
V. Combined complex - high velocity injuries

17. FRACTURE DESCRIPTION
• Location : Extra or Intra articular
• Configuration : Simple : transverse or oblique/ Comminuted.
• Displacement : Radial inclination Radial length Volar tilt intra-
articular incongruity
• Ulna & DRUJ

18. COMPLICATIONS OF DISTAL RADIAL FRACTURES
• Disruption of the triangular fibrocartilage (TFC) complex.
• Scapholunate and lunotriquetral interosseous ligament injuries.
• Ulnar nerve injury
• Carpal tunnel syndrome
• Posttraumatic radiocarpal osteoarthritis6-Heterotopic ossification
• Reflex sympathetic dystrophy (RSD)
• Tendon rupture (extensor pollicis longus)

19. TREATMENT GOALS
• Preserve hand and wrist function
• Realign normal osseous anatomy
• Articular surface
• Promote bony healing
• Allow early finger and elbow ROM

20. OPTIONS FOR TREATMENT
Casting
• Long arm vs. short arm
External Fixation
• Joint-spanning
• Non bridging
Percutaneous pinning
Internal Fixation
• Dorsal plating
• Volar plating
• Combined dorsal/volar plating
• focal (fracture specific) plating

22. INDICATION OF INSTABILITY
1. >10 degrees loss of volar angulation
2. >5 mm of radial shortening
3. >2mm of articular incongruity
4. comminution of cortex across the midaxial line on lateral x-ray
5. comminution of dorsal and palmar cotices
6. Irreducible fracture
7. Loss of reduction at follow up.

23. TECHNIQUE OF CLOSED REDUCTION
Anesthesia (pain relief & decrease muscle spasm)
• Hematoma block
• Intravenous sedation
• Bier block
Traction: finger traps and weights
Reduction 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.

24. NON-ACCEPTABLE REDUCTION
• Radial shortening > 5 mm
• Radial inclination < 10°
• Tilt on lateral projection > 10°dorsal tilt
and > 20° volar tilt
• Intra-articular step-off 2 mm or more
• Articular incongruity 2 mm or more of the
sigmoid notch ( articular surface of distal
radius in DRUJ).

25. AFTER-TREATMENT
Watch for median nerve symptoms
• parasthesia common but should diminish over few hours
• If persist release pressure on cast, take wrist out of flexion
• Acute carpal tunnel: symptoms progress; CTR required
Follow-up x-rays needed in 1-2 weeks to evaluate reduction.
Change to short-arm cast after 2-3 weeks, continue until fracture
healing.

26. INDICATIONS FOR SURGICAL TREATMENT
1. High-energy injury with instability
2. Comminuted displaced intraarticular fracture
3. Open injury
4. Radial inclination < 15°
5. Articular step-off, or gap > 2mm
6. Dorsal tilt > 10 °
7. DRUJ incongruity

27. INDICATION FOR SURGERY
1. Unstable
• 1) Fernandez type II, IV, V and some case in I, III
• 2) Lafontaine criteria > 3 of 5 instability parameters
• 3) Secondary displacement after casting
Lafontaine criteria (1989)
Dorsal angulation > 20°
Ulnar fracture Dorsal comminution
Intraarticular Fx
Age >60

28. 2. Irreducible fracture
1) Double die punch
2) Displaced comminuted PM fragment
3) Articular step off > 2 mm
4) Severe comminution
5) Shortening > 5mm

29. • 3. Unacceptable alignment
1) Radial inclination < 15°
2) Shortening > 5 mm
3) Dorsal tilt > 10°
4) Volar tilt > 20°
5) Articular step off or gap > 2 mm
• 4. Open fracture
• 5. Associated injury

30. COLLES FRACTURE
• A Colles fracture is a fracture
of the distal metaphysis of the
radius with dorsal angulation
and displacement leading to a
silver fork deformity
• Colles fractures are seen more
frequently with advancing age
and in women with
osteoporosis.

31. CLOSED REDUCTION
:Technique
Traction on fingers and counter traction near
elbow by assistant.
Fracture is disimpacted.
Length is established.
Fracture is locked by over flexing and ulnar
deviation of the wrist.
Below elbow cast is applied.

32. CLOSED REDUCTION
Closed reduction and below
elbow cast application under
Hematoma block: Local
anesthetic (2% Xylocaine is
infiltrated into the fracture
hematoma
Closed reduction and below
elbow cast application under
anaesthesia