This document discusses the history and treatment of distal radius fractures. Some key points: - Distal radius fractures are common injuries that were first recognized in the late 18th century, with descriptions of injury patterns evolving over the 19th century. - Treatment has progressed from casting to external fixation to various internal fixation methods like dorsal, volar, and combined plating approaches. - Factors like fracture pattern, displacement, comminution, and articular involvement help determine appropriate treatment, whether closed reduction or open reduction with internal fixation. - The goal of treatment is to restore normal anatomy, allow early motion, and avoid complications like malunion.

1. Dr barun kumar patel
Dnb orthopedic

2.  Common injury
 Potential for functional
impairment and frequent
complications

3.  First surgeon to recognize these injuries was Pouteau 1783. his
work was not widely publicized.
 Later Abraham Colles 1814 gave the classic description of fracture
 Dupuytren brought to the world attention that it is a fracture
rather than a dislocation as it was previously assumed.
 Goyrond 1832 differntiated between dorsal and volar
displacement.
 Barton 1838 described wrist subluxation consequent to
intraarticular fracture of radius which could be dorsal or volar.
 Smith described fracture of distal radius with ‘forward’
displacement.
 Advent of X rays at the end of nineteenth century contributed
much to the understanding of different patterns of injury.

4.  One sixth of all fractures treated in the Emergency
Room
 Bimodal distribution
 less than 30 years (70% men)
 over 50 years (85% women)
 Males age 35 or older - 90 per 100,000 population

5.  Occurs through the distal metaphysis of the radius
 May involve articular surface.
 FOOSH
 forced extension of the carpus,
 impact loading of the distal radius.
 Associated injuries may accompany distal radius
fractures.

6.  History of a FOOSH
 Wrist is typically swolen with ecchymosis and
tender
 Visible deformity of the wrist, with the hand most
commonly displaced in the dorsal direction less
comonly in volar direction
 Movement of the hand and wrist are painful.
 Adequate and accurate assessment of the
neurovascular status of the hand is performed,
before any treatment is carried out.

7.  General physical exam of the patient, including
an evaluation of the injured joint, and a joint
above and below
 Radiographs of the injured wrist-pa and lat
view , oblique view
 CT scan of the distal radius to know extent of
intrarticular involvement

8.  Distal radius – 80% of axial load
 Scaphoid fossa
 Lunate fossa
 Sigmoid notch – DRUJ
 Distal ulna

9.  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

10.  Articular Surface
 Scaphoid facet
 Lunate facet
 Sigmoid notch

12.  Ulnar inclination (avg 23deg)
 Volar inclination (avg 11 to 12deg)
 Radial length (avg 11mm)
 Ulnar variance (+ / - 1mm)

13. Measurement of Radial Length and
Inclination
Inclination = 23
degrees

15. 1: Line connecting dorsal and
volar tip of lunate
2: Line perpendicular to
lunate
3: Line along axis of scaphoid
Scapholunate angle measured between lines 2 and 3
(normal 47 ± 15 degrees)

16.  Intra-articular fxs with multiple
fragments
 centrally impacted fragments
 DRUJ incongruity
Cole et al: J Hand Surg, 1997

17.  Ideal system should describe:
 Type of injury
 Severity
 Evaluation
 Treatment
 Prognosis

18.  Column theory
 Gartland/Werley
 Frykman
 Weber (AO/ASIF)
 Melone
 Fernandez (mechanism)

19. Extra-
articular
Radio-carpal
joint
Radio-ulnar joint
Both joints
{
Same pattern as
odd numbers,
except ulnar
styloid also
fractured

20. Group A: Extra-
articular
Group B: Partial
Intra-articular
Group C:
Complete Intra-
articular

21.  Depends on three basic components of
injury
 1-metaphyseal comminution
 2-intra articular extension
 3-displacement of the fragment

22.  Group i-
simple colles # with no involvement of radial
articular surface
 Group ii-
colles # with intra articula extension without
displacement
 Group iii-
comminuted colles # with intra articular
extension with displacemet
 Group iv-
extra articular undisplaced

24.  Type I Extraarticular, undisplaced
 Type 2 Extraarticular, displaced
 Type 3 Intraarticular, undisplaced
 Type 4 Intraarticular, displaced

25.  Type A Extraarticular
 Type B Partial articular
 B1–radial styloid fracture
 B2–dorsal rim fracture
 B3–volar rim fracture
 B4–die-punch fracture
 Type C Complete articular

26. Depends on the impaction of the lunate on radial
articular surface
 Type i- stable # without displacement
 Type ii-unstable ‘die punch’ with displacement
of the characteristic fragment and comminution
of the ant and post cotices
 type ii A – reducible
 type iiB --irreducible

27.  Type iii- ‘spike fracture’ ,unstable.
Displacement of the articular surface and
also proximal spike of radius
 Type iv- ‘split’ fracture, unstable medial
complex that is severly comminuted with
separation and or rotation of the distal and
proximal fragments
 Type v- explosion injury

29. Rikli & Regazzoni,
1996
3 Columns: radial, intermediate,
medial

30.  Radial Column
Lateral side of
radius
 Intermediate
Column
Ulnar side of
radius
 Ulnar Column
distal ulna
Radial column
Intermediate column
Ulnar column

31.  I. Bending-metaphysis
bending with loss of
palmar tilt and radial
shortening ,DRUJ
injury(Colles, Smith)
 II. Shearing-fractures of
joint surface (Barton,
radial styloid)

32.  III. Compression-
intraarticular fracture
with impaction of
subchondral and
metaphyseal bone (die-
punch)
 IV. Avulsion-fractures of
ligament attachments
(ulna, radial styloid)
 V. Combined/complex -
high velocity injuries

33.  Assess involvement of dorsal or volar rim
 Is comminution mainly volar or dorsal?
 is one of four cortices intact?
 Look for “die-punch” lesions of the
scaphoid or lunate fossa.
 Assess amount of shortening
 Look for DRUJ involvement

34.  COLLES #
-extra articular or intra articular distal radius #
with various combination of
dorsal angulation,
dorsal displacement
radial shift , and
radial shortening
-clinicaly described as dinner fork deformity
-mechanism---fall on to an hyper extended
,radialy deviated wrist with the forearm in
pronation

35.  # distal radius with volar angulation or
volar displacement of the hand and
distal radius
 mechanism—fall on to a flexed wrist
with the forearm fixed in supination
 unstable pattern often requires ORIF
because of difficulty in maintaining
closed reduction

36.  # disdlocation or subluxation of
wrist in which the dorsal or volar
rim of distal radius is displaced
 mechanism-fall on to a dorsiflexed
wrist with the forearm fixed in
pronation
 unstable # requires ORIF

37.  Avulsion # with extrinsic ligaments
remaining attached to styloid fragment
 Mechanism-compression of scaphoid
against styloid with the wrist in
dorsiflexion and ulnar deviation
 Often associated with intercarpal ligament
injury
 Requires ORIF

38. five factors indicative of instability
(1)initial dorsal angulation of more than 20
degrees (volar tilt),
(2) dorsal metaphyseal comminution,
(3) intraarticular involvement,
(4) an associated ulnar fracture, and
(5) patient age older than 60 years

39.  Casting
 Long arm vs short arm
 Sugar-tong splint
 External Fixation
 Joint-spanning
 Non bridging
 Percutaneous pinning
 Internal Fixation
 Dorsal plating
 Volar plating
 Combined dorsal/volar plating
 focal (fracture specific) plating

40.  Preserve hand and wrist function
 Realign normal osseous anatomy
 promote bony healing
 Avoid complications
 Allow early finger and elbow ROM

41.  Low-energy fracture
 Medical co-morbidities
 Minimal displacement-
acceptable alignment

42.  Obtaining and then maintaining an acceptable
reduction.
 Immobilization:
 long arm
 short arm adequate for elderly patients
 Frequent follow-up necessary in order to
diagnose redisplacement.

43.  Anesthesia
 Hematoma block
 Intravenous sedation
 Bier block
 Traction: finger traps and weights
 Reduction Maneuver (dorsally angulated fracture):
 hyperextension of the distal fragment,
 Maintain weighted traction and reduce the distal
to the proximal fragment with pressure applied
to the distal radius.
 Apply well-molded “sugar-tong” splint or cast,
with wrist in neutral to slight flexion.
 Avoid Extreme Positions!

44.  Radial length- within 2-3 mm of the
controlateral wrist
 Palmar tilt- neutral tilt(o degree )
 intrarticular step-off or gap< 2mm
 Radial inclination <5 degree loss
 Carpal malalignment – absent
 Ulnar variance- no more than 2 mm of
shortening compare to ulnar head

45.  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; 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.

46.  Repeat reduction and casting – high rate of failure
 Repeat reduction and percutaneous pinning
 External Fixation
 ORIF

47.  High-energy injury
 Open injury
 Secondary loss of reduction
 Articular comminution, step-off, or gap
 Metaphyseal comminution or bone loss
 Loss of volar buttress with displacement
 DRUJ incongruity

49. External fixation:
The treatment of choice for
distal radius fractures in the
1980’s

51.  Spanning
 Dynamic
 Clyburne
 Agee
 Pennig
 Static
 AO
 Ace
 Non-spanning
 Hoffman 2
 Cobra
 Zimmer
 AO
Neutralize the axial load imparted by physiologic forearm
musculature

52.  A spanning fixator
is one which fixes
distal radius
fractures by
spanning the
carpus; I.e.,
fixation into radius
and metacarpals
 Use for
comminuted
fracture

53.  Used to restore radial length and radial
inclination but palmer tilt is rarely restored
 Supplemental k wire fixation is needed to
prevent loss of palmer tilt and some degree of
colapse
 Pins are retained for 6 to 8 weeks
 Overdistraction results in finger stiffness

55.  Mal-union
 Pin track infection
 Finger stiffness
 Loss of reduction; early vs late
 Tendon rupture

56.  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.
 Indicated for extra articular or minimal
intra articular dorsaly displaced fracture
 Minimum 1 cm of intact volar cortex is
required to give purchase for the pins
 Better to preserve volar tilt and carpal
malalignment

58. Courtesy of Hill
Hastings,MD

59.  Bulky
 Poor screw hold in porosis and comminution
 Screws do not buttress
 Cutaneous radial nerve injury
 Pin tract infection
 Reflex sympathetic dystrophy

60.  Wrist is immobilized in a supinated position
with sugar tongue splint for 10 days
 External fixator frame is removed at 6 weeks
 Any supplemental pins are kept in place for 8
weeks
 Active and passive finger motion is begun as
soon as the anesthesia wears off

62.  most common radial styloid pinning +
dorsal-ulnar corner of radius pinning
 supplemental immobilization with cast,
splint
 in conjunction with external fixation
(Augmented external fixation)

63.  2 radial styloid pins-
-radial styloid is pinned to proximal shaft
in reduced position
 excellent anatomic 82%
 good-excellent functional results 100%
 radial styloid with dorsal ulnar –
-after radial styloid fixation the
intermediate column is pinned from
dorsal ulnar to proximal radial
 excellent anatomic results in 90%

64.  intrafocal pinning
through fracture site
 buttress against
displacement
 Drawback-tendency to
translate distal fragment
in opposite direction

65.  Useful for elevation of depressed articular
fragments and bone grafting of metaphyseal
defects
 required if articular fragments can not be
adequately reduced with percutaneous
methods

66.  Based on location of comminution.
 Dorsal approach for dorsally angulated
fractures.
 Volar approach for volar rim fractures
 Radial styloid approach for buttressing of
styloid
 Combined approaches needed for high-energy
fractures with significant axial impaction.

67. Classical Henry
approach(chung)
Extended carpal tunnel approach
VOLAR

68. Volar –Henry Approach

69. Radial to FCR

70. Incision carried to flexor
carpi radialis sheath
Flexor pollicis longus muscle
belly is partially detached
from radius to expose
pronator quadratus

71.  Fracture line is
exposed
Volar plate positioned, insertion
of first screw

72.  Pronator quadratus sutured
to edge of brachioradialis

74. Courtesy J. Orbay, MD

75.  At 1 week, the sutures are removed and active
wrist motion is begun when there is confidence
in fracture stability
 A removable Orthoplast splint is worn for 6
weeks.

76. -
DORSAL
APPROACH
3rd DC –EPL
(extensile)
1-2nd DC

77. Dorsal Plating, PCP and Ex Fix

78.  Generally not prefere because of high rate of
complication like
- tendon dysfunction and rupture
- tenosynovitis of extensor tendons
 indicated for-
dorsal die-punch fractures or fractures
with displaced dorsal lunate facet fragments

80.  Finger and other joint upper extremity
exercises are begun immediately
 If a splint was applied, it is removed at 3 weeks
 When union is achieved, the distraction plate is
removed and range-of-motion exercises are
begun

81. -less tendon irritation than dorsal

82. Fixed angle locked screws
,,variable angle

84.  radial column,
 dorsal cortical wall,
 dorsal ulnar split,
 volar rim, and
 the central
intraarticular
fragment

85.  Radial pin-plate
For stabilization of radial column
Ulnar pin-plate
for stabilization of dorsal ulnar
split fragment

86. simultaneously
stabilization of
dorsal wall fragment
and intraarticular
component

87. Radial shortening,
comminution
Dorsal angulation
Indication for Volar
and Dorsal Plating

88. Volar approach,
application
buttress plate

89. Dorsal approach,
application of 2 “L”
buttress plates

90. EPL Tendon

91. Extensor retinaculum repaired
beneath EPL to prevent erosion
against plate- EPL left transposed

92.  reduce articular incongruities
 also diagnose associated soft tissue lesions
 minimally invasive

93.  Indicated for
1-complex articular fracture without
metaphyseal comminution
2-# with evidence of substantial
interosseous ligament or TFCC injury
without a large ulnar styloid fragment.
 Timing-between 5 to 15 days post injury to
prevent extravasation of irrigation fluid
into the surrounding soft tissue

94.  Arthritis/arthrosis
 Loss of motion
 Hardware complications
 Nerve compression/neuritis
 Osteomyelitis
 Dupuytren contracture
 Persistent pain/pain syndromes (CRPS)
 Tendon (rupture, lag, trigger, tenosynovitis)
 Delayed union/nonunion/malunion
 Radioulnar (synostosis, disturbance)

95.  ORIF better in high-energy fractures associated with
depression of articular surface
 ORIF gives better anatomic restoration, although not
necessarily higher patient satisfaction.

96.  External fixators still have a role in the
treatment of distal radius fractures
 Spanning ex fix does not completely correct
fracture deformity by itself
 Should usually combined with percutaneous
pins (augmented fixation)

97.  new plating techniques allow for accurate
and rigid fixation of fragments
 Plating allows early wrist ROM
 Volar, smaller and more anatomic plates are
better tolerated
 combination treatment is often needed

99. Colles; “The wrist will regain perfect freedom in all of its
motions and be completely exempt from pain” (1814)
 Generally true for low demand individuals
 Direct relation between residual deformity and
disability
 Quality of reduction more important than method of
immobilisation