A 18-year-old Thai male presented to the hospital complaining of left wrist pain for 4 hours after falling while playing football. Imaging showed a closed fracture at the distal end of the radius. The fracture was treated with a short arm cast. Distal radius fractures are common orthopedic injuries that can be classified in several ways. Treatment may involve closed reduction and casting or surgical fixation depending on the type and displacement of the fracture. Complications can include nerve issues, tendon problems, malunion, and arthritis.

1. EXTERN
CONFERENCE
EXTERN WARISA NGOCHANTHRA

2. CASE
• ผู้ป่วยชายไทย อายุ 18 ปี
• อาชีพ นักเรียน
• ภูมิลาเนา จ.นครราชสีมา

3. CASE
• CHIEF COMPLAIN
เจ็บข้อมือข้างซ้าย 4 ชั่วโมงก่อนมาโรงพยาบาล

4. PRIMARY SURVEY
• A : able to talk, not tender at posterior
midline of neck, full ROM of neck
• B : equal breath sound, clear both lung
• C : v/s stable, no active bleed
• D : E4V5M6 pupil 2 mm RTLBE
• E : no external bleeding, no open fracture

5. SECONDARY SURVEY
• A : no allergy
• M : no current medication
• P : no underlying
• L : last meal at 16.00 pm
• E : 4 ชั่วโมง PTA ขณะผู้ป่วยเล่นฟุตบอล ได้ล้มลงแล้วเอามือ
ข้างซ้ายยันพื้น จากนั้นรู้สึกเจ็บข้อมือข้างซ้าย บริเวณข้อมือบวม
เล็กน้อย ขยับได้ ไม่มีแผลเปิด

6. PHYSICAL EXAMINATION
• A young thai man, good consciousness, well
cooperative
• V/S : BT 36.8 PR 96 RR 18 BP 116/98
• HEENT : not pale conjunctivae, anicteric
sclerae
• Heart : normal s1s2, no murmur
• Lungs : clear both lungs

7. PHYSICAL EXAMINATION
• Extremities : No wound, no defornities, Tender
at radial side of left wrist, mild swelling, full
ROM, cap refill < 2 sec, radial pulse 2+
• Neurovascular : intact

8. IMAGING

9. IMAGING

10. DIAGNOSIS
• Closed fracture at left Distal end of radius

11. MANAGEMENT
• On Short arm AP slab
• F/u 2 weeks
• Pain contral
– Paracetamol

12. IMAGING after on slab

13. DISTAL RADIUS
FRACTURE

14. DISTAL RADIUS FRACTURE
• Most common orthopaedic injury with a bimodal
distribution
– younger patients - high energy
– older patients - low energy / falls
• 50% intra-articular

15. DISTAL RADIUS FRACTURE
• Emergency condition
– compartment syndrome
– median nerve neuropathy
– opened fracture
• Associated injuries
– DRUJ injuries must be evaluated
– radial styloid fx - indication of higher energy
– soft tissue injuries in 70%

16. DISTAL RADIUS FRACTURE

17. CLASSIFICATION
• Fernandez: based on mechanism of injury
• Frykman: based on joint involvement (radiocarpal
and/or radioulnar) +/- ulnar styloid fx
• Melone: divides intra-articular fxs into 4 types based
on displacement
• AO: comprehensive but cumbersome

18. CLASSIFICATION
• Fernandez: based on mechanism of injury

19. Common distal radius fracture
Colles fracture
• a fracture of the distal metaphysis of the radius with
dorsal angulation and displacement
• very common extra-articular fractures of the distal
radius
• a fall onto an outstretched hand
• common in patients with osteoporosis, and as such,
they are most frequently seen in elderly women

20. Common distal radius fracture
Colles fracture

21. Common distal radius fracture
Smith's fracture
• known as a reverse Colles' fracture or Goyrand-
Smith's
• occur in younger patients
• high energy trauma on the volar flexed wrist.

22. Common distal radius fracture

23. Common distal radius fracture
Barthon's fracture
• Intra-articular fracture
• Shearing force
• Volar-type(most
common)/Dorsal-type
• Usually associcte with carpal
bone dislocate
• These fractures have a great
tendency for redislocation
and malunion.

24. Common distal radius fracture
Die-punch fracture
• a depression fracture of the lunate fossa of the distal
radius.
• It is the result of a transverse load through the lunate.

25. RADIOGRAPH

26. RADIOGRAPH

27. TREATMENT
Successful outcomes correlate with
• accuracy of articular reduction
• restoration of anatomic relationships
• early efforts to regain motion of wrist and fingers

28. TREATMENT
Nonoperative
• closed reduction and cast immobilization
– indications
• extra-articular
• <5mm radial shortening
• dorsal angulation <5° or within 20° of contralateral
distal radius

29. TREATMENT
Nonoperative
• closed reduction and cast immobilization

30. TREATMENT
closed reduction and cast immobilization
• Technique
– rehabilitation
• Outcomes
– repeat closed reductions have 50% less than satisfactory
results
• Complications
– acute carpal tunnel syndrome
– EPL rupture

31. TREATMENT
Operative
• surgical fixation (CRPP, External Fixation,
ORIF)
– indications: radiographic findings indicating
instability (pre-reduction radiographs best
predictor of stability)

32. TREATMENT
• displaced intra-articular fx
• volar or dorsal comminution
• articular margins fxs
• severe osteoporosis
• dorsal angulation >5° or >20° of contralateral distal radius
• >5mm radial shortening
• comminuted and displaced extra-articular fxs (Smith's fx)
• progressive loss of volar tilt and loss of radial length
following closed reduction and casting
• associated ulnar styloid fractures do not require fixation

33. TREATMENT
Operation
• Percutaneous Pinning
– can maintain sagittal length/alignment in extra-articular
fxs with stable volar cortex
– cannot maintain length/alignment when unstable or
comminuted volar cortex
• External Fixation
– alone cannot reliably restore 10 degree palmar tilt
therefore usually combined with percutaneous pinning
technique or plate fixation

34. TREATMENT
Operation
• ORIF
– significant articular displacement (>2mm)
– dorsal and volar Barton fxs
– volar comminution
– metaphyseal-diaphyseal extension
– associated distal ulnar shaft fxs
– die-punch fxs

35. COMPLICATIONS
• Median nerve neuropathy (CTS)
• Ulnar nerve neuropathy
• EPL rupture
• Radiocarpal arthrosis (2-30%)
• Malunion and Nonunion
• ECU or EDM entrapment
• Compartment syndrome