This document discusses fractures of the distal radius, including Colles' fractures (transverse fractures with dorsal displacement), Smith's fractures (volar displacement), and Barton's fractures (dorsal or volar rim avulsions). Treatment depends on the fracture type and degree of displacement/fragmentation. Displaced fractures may be reduced manually or surgically with K-wires, plates, or external fixation. Outcomes depend on restoring length, alignment, and congruity while allowing early motion. Complications include malunion, nonunion, instability, and arthritis.

1. Fracture of the distal Radius
Dr. Ashiqur Rahman
Resident Orthopedics
Dhaka Medical college Hospital

2. Introduction
 Historically, distal radial # have been classified using eponymous
terms such as Colle’s, Smith’s, or Barton’s fracture.
 But these names can lead to confusion & misunderstanding.
 Treatment options depend on whether the # is intra-articular or
extra-articular & degree of fragmentation of the joint surface & the
metaphysis.
 The wrist can suffer substantial ligamentous injury causing instability
to the carpus or distal radio-ulnar joint(DRUJ).

4. Low energy dorsally displaced # (‘Colles’ fracture)
 The injury that Abraham Colles described in 1814 (‘Colles fracture’) is
a transverse fracture of the radius just above the wrist, with dorsal
displacement of the distal fragment.
 It is the most common of all fractures in older people, the high
incidence being related to the onset of postmenopausal osteoporosis.
 Thus the patient is usually an older woman who gives a history of
falling on her outstretched hand.

11. Mechanism of injury & pathological antomy
 Force is applied in the length of the forearm with the wrist in
extension.
 The bone fractures at the cortico-cancellous junction & the distal
fragment collapses into extension, dorsal displacement, radial tilt and
shortening.

14. Clinical features
- Pain,
- swelling,
- tenderness &
- irregularity of the lower end of the radius.
- ‘Dinner fork’ deformity:
with prominence on the back of the wrist &
a depression in front.

15. Imaging
- X-ray shows there is a transverse # of the radius @
the cortico-cancellous junction.
- & often the ulnar styloid process is broken off.
- The radial fragment is impacted into radius & backward tilt.
- Sometimes, there is an intra-articular #;
sometimes it is severely fragmented.
- A CT scan in very helpful in planning Rx.

17. Treatment
 Un-displaced fracture:
- If the # is un-displaced or only very slightly displaced, a dorsal
splint is applied for a day or two until the swelling has resolved,
then the cast is completed.
- An X-ray is taken @ 10 – 14 days to ensure that the fracture has
not slipped; if it has, surgery may be required.
- If not, the cast usually be removed after 05 weeks to allow
mobilization.

19. Displaced fracture
 Displaced # must be reduced under GA (Hematoma block, Bier’s
block, axillary block or general anesthesia).
 Procedure:
- The hand is grasped & longitudinal traction is applied.
- Sometimes, with extension of the wrist to disimpact the
fragments.
- The distal fragment is then pushed into place by pressing on the
dorsum while manipulating the wrist into flexion, ulnar deviation
& pronation.

21.  If it is satisfactory, a dorsal plaster slab is applied, extending from just
below the elbow to the metacarpal necks & two-thirds of the way
round the circumference of the wrist.
 The position is then checked by X-ray.
 Extreme positions of flexion & ulnar deviation must be avoided; 20°
in each direction is adequate.

22.  The arm is kept elevated for the next day or two; shoulder, elbow &
finger exercises are started as soon as possible.
 If the fingers become swollen, cyanosed or painful, there should be
no hesitation in splitting the bandage.
 At approximately 07 days, and if satisfactory then again at about 14
days, fresh X-ray is taken, this is because re-displacement is not
uncommon.
 Another X-ray at 18 – 20 days, just prior to the fracture being too
‘Sticky’ to manipulate again.

23.  If the position is probably not compatible with a good outcome & if
the risks inherent in surgery are understood, manipulation & fixation
with either percutaneous wires or volar locking plate are undertaken.
 However, in older patient with low functional demands, modest
degrees of displacement should be accepted because:
- Outcome in this pt. is not so dependent on anatomical
perfection.
- Fixation of the fragile bone can be very difficult & is not
without complications.

24. Impacted or Fragmented low-energy distal radial
fractures
 With substantial impaction or
fragmentation in osteoporotic
bone, manipulation & plaster
immobilization alone may be
insufficient.
 The # can sometimes be reduced
& held with percutaneous wires
or a volar locking plate.

25.  But, if impaction is severe, even this
may not be enough to hold all the
fragments or maintain length.
 In that case, other techniques, such
as dorsal plating, locked intra-
medullary nails, external fixators,
internal plate bridging the radius to
the 3rd metacarpal & bone grafts
(Synthetic or autogenous) are
considered.

34. Poor outcome is associated with:
(i) Loss of radial length >3mm.
(ii) Dorsal tilt >15° from neutral depending on age & function.
(iii) Palmar tilt >20° from neutral.

37. Volar displaced fracture(‘Smith fracture’)
 Smith described a # about 20
years later in which the distal
fragment is angulated or
displaced volarward.
 It is caused by a fall on the back
of the hand & is an unstable
injury due to force generated by
the long flexors crossing the wrist

38. Clinical features
 Wrist pain
 Garden - spade deformity

39. Imaging
- There is # through the distal radial metaphysis.
- A lateral view shows that the distal fragment is
displaced or tilted anteriorly.

40. Treatment
1. Conservative:
- These fractures can be reduced by traction,
supination & extension of the wrist.
- Forearm is immobilized in a cast for 06
weeks.
- X-rays should be taken @ 7 – 10 days to
ensure that the # has not slipped, when a plate
is used.

41. 2. Surgery:
- The risk of placement is
high & most advocate early
surgical intervention with a volar
locking plate t buttress the distal
fragment.

42. Fractured Radial Styloid
 The injury is caused by forced
radial deviation of the wrist &
may occur after a fall, or when a
starting handle ‘kick back’ – the
so called ‘Chauffeur’s fracture’.
 The fracture line transverse or
oblique, extending laterally to
the articular surface of the
radius.

43.  The injury is often undisplaced but
the injury is commonly associated with
a carpal ligament injury & this should
be looked for.
 The energy transfer which breaks the
radial styloid can rupture the
scapholunate ligament or # of the
scaphoid.
 These associated injuries must always
be carefully excluded.

44. Treatment
 If there is displacement, it is
reduced & the wrist is held in
ulnar deviation by a plaster slab
round the outer forearm,
extending from below elbow to
the metacarpal necks.
 Imperfect reduction may lead to
osteoarthritis.

45.  therefore if closed, the fragment
should be perfectly reduced &
held with a k-wire or even better
buried cannulated screw.
 Associated ligamentous injuries
must always be carefully
excluded.

46. Fragmented intra-articular fractures
 In the young adult, a fragmented intra-articular fracture is a high-
energy injury.
 A poor outcome will probably result unless intra-articular congruity,
fracture alignment & length are restored & movements started as
soon as possible.

47. Imaging
(i) X-rays : AP & Lateral
(ii) CT scan
 Are useful to show the fragment alignment.

48. Treatment
1. Conservative :
- Simple manipulation under anesthesia & cast may be
helpful.
- X-rays are needed at about 07 days.
- If the anatomy is not restored, then either closed
reduction with percutaneous wires & an open
reduction may well be necessary.

49. 2. Surgery :
- All fragments must be
reduced into a good
position & held in a stable
manner.
- Volar locking plate are
particularly useful.

50. Complications
A. Early :
(i) Circulatory problem:
- Early finger movements & avoiding undue flexion of the
elbow are important to encourage venous drainage.
(ii) Nerve injury:
- Compression of the median nerve in the carpal tunnel is
fairly common.
(iii) Complex regional pain syndrome(CRPS):
- Previously known as Reflex sympathetic dystrophy or
sudeck’s atrophy.

51. (iii) Ulnar corner pain & instability:
- Due avulsion of ulnar styloid.
(iv) Associated injury to the carpus.
(v) Re-displacement

52. B. Late:
(i) Malunion
(ii) Delayed union & non-union
(iii) Tendon rupture :
- Rupture of the EPL occurs a few weeks after an
apparently trivial undisplaced # of the lower radius.
- The FPL is vulnerable with a misplaced volar plate.
(iv) Carpal instability
(v) Secondary osteoarthritis

55. Dorsal Barton’s Fracture
Rim avulsion fractures of the distal radius in which dorsal half of the
distal radius sheaf off with intact volar half & the fragment moves
dorsally carrying the carpus with it.
Mechanism:
- Fall with dorsiflexion and pronation of the distal forearm on a
flexed wrist.
Clinical Features:
- Pain swelling
- tenderness over the wrist
- restricted wrist movements with painful dorsiflexion

56. Radiology:
- Best seen on the lateral view. Dorsal lip of distal radial articular
surface is displaced proximally and posteriorly and may be
associated with dorsal subluxation of the wrist.
Treatment:
(i) Conservative:
- Short arm cast with wrist in neutral position.
(ii) Surgery:
- Unstable fracture is fixed by percutaneous pins or small screws.
- OR + with small plate and screws can be done but due to the
extensor tendons may not be good option (Avoid plate
immediately under extensor tendon).

58. Volar Barton fracture
Rim avulsion fracture of the distal radius in which volar half of the
distal radius shear off with intact dorsal half & the fragment moves
forwards carrying the carpus with it.
Mechanism:
• It is due to palmar tensile stress and dorsal shear stress and is usually
combined with Radial styloid fracture.
Clinical Features
• It consists of pain, swelling, tenderness and loss of wrist movements.
Palmar flexion is grossly restricted and painful.

59. Radiograph:
- Volar rim of distal radial articular surface is displaced forwards.
- May be associated with volar subluxation of the wrist.
Treatment:
(i) Conservative:
- Reduction is simple, but retention is difficult.
- Long arm cast is used.

60. Surgery:
- If reduction does not remain satisfactorily then fixation
with K wire.
- External fixators and buttress plate, etc. may be done.
- Ellis T-shaped buttress plate fixation is the preferred
method of treatment.