Summary Distal radius fractures are the most common orthopaedic injury and generally result from fall on an outstretched hand. Diagnosis is made clinically and radiographically with orthogonal radiographs of the wrist Treatment can be nonoperative or operative depending on fracture stability and fracture displacement as well as patient age and activity demands Epidemiology Incidence accounts for 17.5% of all fractures in adults lifetime risk is 15% for women and 2% for men Demographics more common in females (2-3:1) bimodal distribution younger patients due to high energy mechanisms older patients due to low energy mechanisms (i.e. FOOSH) considered fragility fracture and warrants further bone density workup Anatomic location Approximately 65% extra-articular, 10% partial articular, and 25% complete Risk factors osteoporosis high incidence of distal radius fractures in women > 50 years old distal radius fractures are a predictor of subsequent fractures DEXA scan is recommended for older patients with distal radius fractures and/or lower energy mechanisms Etiology Pathophysiology mechanism of injury fall on outstretched hand (FOOSH) from standing height is most common in older population higher energy mechanism more common in younger patients, particularly motor vehicle collisions Associated conditions DRUJ injuries radial styloid fractures indicates higher energy mechanism soft tissue injuries - seen in 70% TFCC injury (40%) scapholunate ligament injury (30%) lunotriquetral ligament injury (15%) Anatomy Osteology distal radius responsible for 80% of axial load articulates with scaphoid via scaphoid fossa lunate via lunate fossa distal ulna via ulnar/sigmoid notch comprised of 3 columns radial column includes the radial styloid and scaphoid fossa radial styloid is a relatively volar structure important consideration for placement of radial styloid pin or screw functions attachment sites for the brachioradialis tendon, long radiolunate ligament, and radioscaphocapitate ligament radioscaphocapitate ligament prevents ulnar translation of the carpus serves as a buttress to resist radial carpal translation functions as a load-bearing platform for activities performed with the wrist in ulnar deviation holds the carpus out to length radially, allowing a more uniform distribution of load across the scaphoid and lunate facets intermediate column lunate fossa functions transmits load from the carpus to the forearm origin of short radiolunate ligament important for radiocarpal joint stability ulnar column includes the TFCC and distal ulna functions stability of the DRUJ forearm rotation Lister's Tubercle On dorsal surface of distal radius, approximately 1 cm proximal to articular surface EPL tendon lies just ulnar to tubercle before taking sharp turn into the thumb Important landmark to avoid EPL attritional rupture with long volar plate screws Watershed region Most volar and prominent aspect of distal radius Lunate portion is most prominent with vital short radiolunate ligament attachment for radiocarpal stability Important region to remain proximal to for volar plate fixation Classification Fernandez based on mechanism of injury Frykman based on joint involvement (radiocarpal and/or radioulnar) +/- ulnar styloid fracture Melone divides intra-articular fractures into 4 types based on displacement AO comprehensive but cumbersome Eponyms Eponyms Name Description Illustration X-ray Die-punch fx Depressed fracture of the lunate fossa of the articular surface of the distal radius Volar Barton Fracture-dislocation of radiocarpal joint with intra-articular fx involving the volar lip Dorsal Barton Fracture-dislocation of radiocarpal joint with intra-articular fx involving the dorsal lip Chauffer's fx Transverse or oblique radial styloid fx Colles' fx Dorsally angulated, extra-articular fx Smith's fx Volarly angulated, extra-articular fx Presentation History usually a fall onto outstretched hand (FOOSH) Symptoms wrist pain wrist swelling wrist deformity Physical exam inspection ecchymosis & swelling diffuse tenderness visible deformity if displaced motion limited by pain Imaging Radiographs recommended views AP lateral oblique findings Radiographic criteria Measurement Normal Acceptable criteria Radial height (AP) 13mm < 5mm shortening Radial inclination (AP) 23° Change < 5° Articular stepoff (AP) Congruous < 2 mm stepoff Volar tilt (Lateral) 11° Dorsal angulation < 5° or within 20° of contralateral distal radius CT indications evaluate intra-articular involvement surgical planning MRI indications evaluate for soft tissue injury TFCC injuries scapholunate ligament injuries (DISI) lunotriquetral injuries (VISI) Treatment Nonoperative closed reduction and immobilization indications extra-articular < 5mm radial shortening dorsal angulation < 5° or within 20° of contralateral distal radius technique immobilization can be in below arm cast or splint depending on fracture pattern Operative closed reduction percutaneous pinning (CRPP) indications extra-articular fracture with stable volar cortex outcomes 82-90% good results if used appropriately open reduction internal fixation (ORIF) indications radiographic findings indicating instability (pre-reduction radiographs best predictor of stability) dorsal angulation > 5° or > 20° of contralateral distal radius volar or dorsal comminution displaced intra-articular fractures > 2mm radial shortening > 5mm associated ulnar fracture associated ulnar styloid fractures do not require fixation severe osteoporosis articular margin fractures (dorsal and volar Barton's fractures) the volar ulnar corner (critical corner) supports the volar lunate facet with its strong radiolunate ligament attachments failure to address this fragment can result in volar carpal subluxation comminuted and displaced extra-articular fractures (Smith's fractures) die-punch fractures progressive loss of volar tilt and radial length following closed reduction and casting external fixation (Exfix) indications open fractures highly comminuted fractures medically unstable patients unable to undergo a lengthy procedure outcomes important adjunct with 80-90% good/excellent results alone cannot reliably restore 10° palmar tilt therefore usually combined with percutaneous pinning technique or plate fixation Techniques Closed reduction and immobilization technique reduction requires adequate anesthesia apply longitudinal traction and volar/dorsal pressure to the distal fracture fragment immobilization can be in below elbow cast or splint depending on fracture pattern and patient avoid positions of extreme flexion and ulnar deviation (Cotton-Loder Position) due to risk of carpal tunnel syndrome rehabilitation no significant benefit of physical therapy over home exercises for simple distal radius fractures treated with cast immobilization outcomes repeat closed reductions have < 50% satisfactory results LaFontaine predictors of instability radial shortening is the most predictive of instability, followed by dorsal comminution severe osteoporosis associated ulnar fracture dorsal comminution > 50%, palmar comminution, intraarticular comminution dorsal angulation > 20° initial displacement > 1cm initial radial shortening > 5mm higher loss of reduction with 3 or more of LaFontaine criteria Meta-analyses and systematic reviews demonstrate no difference in functional outcomes between closed treatment versus operative methods in elderly patients (>65 years old) complications specific to this treatment acute carpal tunnel syndrome EPL rupture CRPP technique Kapandji intrafocal technique K wires are placed dorsally into the fracture and used as reduction tools until they are driven into the proximal radius Rayhack technique with arthroscopically assisted reduction complications specific to this treatment radial sensory nerve injury pin tract infections ORIF technique guides distal radius extra-articular fracture ORIF with volar approach distal radius intra-articular fracture ORIF with dorsal approach types volar plating preferred over dorsal plating associated with irritation of both flexor and extensor tendons rupture of FPL is most common with volar plates associated with plate placement distal to watershed area, the most volar margin of the radius closest to the flexor tendons can have hyperesthesia over the base of the thenar eminence due to palmar cutaneous nerve injury during retraction of the digital flexor tendons when plating the distal radius new volar locking plates offer improved support to subchondral bone dorsal plating indicated for displaced intra-articular distal radius fractures with dorsal comminution, polytrauma patients, or elderly patients can allow immediate post operative weight bearing (front wheel walker assistance) avoids complications associated with wrist-spanning external fixators but similarly must be removed via second surgery historically associated with extensor tendon irritation and rupture technique can combine with external fixation and percutaneous pinning perform bone grafting if complex and comminuted the utilization of calcium phosphate demonstrates radiographic evidence of successful incorporation into the host bone at 1 year postoperatively calcium phosphate possesses osteoconductive and osteointegration capabilities allowing for incorporation into host bone study showed improved results with arthroscopically-assisted reduction volar lunate facet fragments may require fragment-specific fixation to prevent early postoperative failure complications specific to this treatment screw penetration into the radiocarpal joint or DRUJ assess intra-articular screws with a 23 degree elevated lateral view assess dorsal cortex penetration with a skyline view tendon rupture outcomes no benefit of therapist-directed physical therapy compared to home exercise program External fixation technique guides distal radius fracture spanning external fixator distal radius fracture non-spanning external fixator types spanning ex-fix useful for fractures with small articular fragment non-spanning ex-fix useful for fractures with large articular fragment technique relies on ligamentotaxis to maintain reduction place radial shaft pins under direct visualization to avoid injury to superficial radial nerve 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 complications specific to this treatment malunion nonunion stiffness and decreased grip strength pin complications (infections, fractures through pin site, skin difficulties) pin site care comprising daily showers and dry dressings recommended neurologic (iatrogenic injury to radial sensory nerve, median neuropathy, RSD) Complications Median nerve neuropathy (CTS) incidence most frequent neurologic complication seen in 1-12% of low energy fxs and 30% of high energy fxs risk factors prevent by avoiding immobilization in excessive wrist flexion and ulnar deviation (Cotton-Loder position) treatment acute carpal tunnel release indications progressive paresthesias, weakness in thumb opposition paresthesias that do not respond to reduction and last > 24-48 hours Ulnar nerve neuropathy risk factors DRUJ injury EPL rupture risk factors nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the EPL tendon extensor mechanism is thought to impinge on the tendon following a nondisplaced fracture and causes either a mechanical attrition or a local area of ischemia in the tendon volar plating with screw fixation that penetrates the dorsal cortex and is proud dorsally treatment EIP to EPL transfer FPL rupture risk factors very distal volar plate placement on the radius (distal to watershed line) is associated with FPL rupture due to physical contact of tendon on plate and subsequent tendinopathy Radiocarpal arthrosis (2-30%) incidence 90% young adults will develop symptomatic arthrosis if articular stepoff > 1-2mm may also be nonsymptomatic Malunion/nonunion intra-articular malunion treatment revision at > 6 weeks extra-articular angulation malunion dorsal angulation > 10° from neutral results in increased stiffness of the interosseous membrane and limitation of simulated forearm pronation and supination treatment opening wedge osteotomy with ORIF and bone grafting delayed procedure associated with higher need for bone grafting and a more difficult procedure radial shortening malunion radial shortening associated with greatest loss of wrist function and degenerative changes in extra-articular fractures treatment ulnar shortening ECU or EDM entrapment risk factors DRUJ injury Compartment syndrome RSD/CRPS prevention AAOS 2010 clinical practice guidelines recommend vitamin C supplementation to prevent incidence of RSD postoperatively subsequent analyses show no benefit to vitamin C strong evidence to suggest the efficacy of prompt physiotherapy, lidocaine, ketamine, bisphosphonates, sympathectomy and brachial plexus blocks Prognosis Poor functional outcomes associated with worker's compensation low socioeconomic status low education levels low bone density Successful outcomes correlate with accuracy of articular reduction restoration of anatomic relationships early efforts to regain motion of wrist and fingers