BACKGROUND

In the times of Hippocrates and Galen, distal radius fractures (DRFs) were thought to be wrist
dislocations. Pouteau first varied from this tradition when he described a variety of forearm
fractures in the French literature, including a DRF. As a result, DRFs are termed Pouteau
fractures in the French-speaking world. However, politics and communications being what
they were, the English-speaking world did not recognize the Pouteau description.
The Irish surgeon Abraham Colles described DRFs in the 1814 volume of the Edinburgh
Medical Surgical Journal. Although his description was based on clinical examination alone
(because radiography had not yet been invented), it is quite accurate, and it is Colles' name
that is most often associated with this fracture in the English-speaking world. Colles stated,
"One consolation only remains, that the limb will at some remote period again enjoy perfect
freedom in all of its motions and be completely exempt from pain...." This claim that all
DRFs, despite displacement, will fare well has been a source of criticism.
Over time, other eponyms have been added to the various subclassifications of DRFs, such as
the Smith fracture, Barton fracture, and volar Barton fracture. The fractures are also referred
to as various stages of classification systems, such as a Melone IV or an AO (ie,
Arbeitsgemeinschaft fr Osteosynthese [Association for the Study of Osteosynthesis]) C3
fracture, or are referred to the region of the fracture (eg, a radial styloid or a lunate facet
fracture), or have a historical explanation (chauffeur's fracture, so called because a chauffeur
sustained this injury when he tried to crank-start a car and it backfired).
In current practice, as a result of greater knowledge of the varieties of fracture configurations,
eponyms tend to be avoided, and a direct description of the fracture is preferred. The term
DRF properly covers all fractures of the distal articular and metaphyseal areas. Although all
classification systems have serious problems, there is general agreement on the meaning of at
least some of the classification terms (eg, Melone IV or AO C3 fracture), and these terms do
add some degree of specificity and understanding to the generic designation DRF.

Problem
The ultimate aim of treatment is to restore each patient to his or her prior level of functioning.
The specific goals, therefore, will not be the same in all patients. For example, a 21-year-old
athlete wants to resume competition, but an 82-year-old person usually only wants to return
to activities of daily living (ADLs).[1, 2]
Because goals differ, treatment options differ as well. In addition, because people now remain
active until an older age, the definition of the phrase "prior level of functioning" is changing.
For example, a 92-year-old patient who was being treated in the emergency department had
only one concern when conversing with his physician: how soon he could return to playing
golf (he had a tournament the next week). Treatment goals, therefore, must be tailored to each
patient. Specifically, treatment should be determined not by age but by activity level.

Epidemiology
Frequency

Distal radius fractures (DRFs) are among the most common type of fracture, and many
authors state that they are the most common type of fracture. DRFs have a bimodal
distribution, with a peak in younger persons (aged 18-25 years) and a second peak in older
persons (aged >65 years). The mechanism of injury is unique to each group, with high-energy
injuries being more common in the younger group and low-energy injuries being more
common in the older group.

Etiology
Younger patients have stronger bone, and thus, more energy is required to create a fracture in
these individuals. Motorcycle accidents, falls from a height, and similar situations are
common causes of a distal radius fracture (DRF). Trauma is the leading cause of death in the
15- to 24-year-old age group, and this is also reflected in the incidence of lesser traumas.
Older patients have much weaker bones and can sustain a DRF from simply falling on an
outstretched hand in a ground-level fall. An increasing awareness of osteoporosis has led to
these injuries being termed fragility fractures, with the implication that a workup for
osteoporosis should be a standard part of treatment. As the population lives longer, the
frequency of this type of fracture will increase.

Pathophysiology
The pathophysiology of a fracture is rather obvious: more load is imparted to a bone than the
bone can sustain. Osteoporotic bone can break with very low impact. However, the patient
should always be questioned regarding the circumstances of the injury, especially if he or she
is older. Heart attacks or transient ischemic attacks can cause a distal radius fracture (DRF)
and should not be overlooked.
In addition, more problems may be involved with the injury than just the fracture. A useful
perspective is that a DRF is a soft-tissue injury surrounding a broken bone, and the
immediacy of the radiographic diagnosis should not distract the surgeon from carefully
assessing systemic issues or forearm soft-tissue issues.[3]

Presentation
The history should be directed toward ascertaining the probable amount of energy involved.
A fall from 20 feet can be associated with a larger and more complex constellation of injuries
(ie, beyond the fracture seen on the radiograph) than would be seen with a fall from a
standing position. A history of prior fractures should be sought. A history of fragility fractures
helps predict the stability of any reduction. A history of multiple high-energy fractures in a
younger patient helps predict the ability of the patient to comply with directions.
The median nerve is always compressed after a fall on the palmar aspect of the hand that
results in a distal radius fracture (DRF), and the chart note should specifically document the
quality (not just the presence or absence) of median nerve function.
Most therapies for DRF have implications for the median nerve. A cast or splint without a
reduction may result in median nerve compromise due to pressure. A reduction, whether

closed or open, involves some level of anesthesia, temporarily compromising the ability to
assess the median nerve. Careful documentation of median nerve function at the first
assessment is critical to planning and assessing treatment, not to mention protecting the
surgeon from subsequent claims. DRFs are overrepresented in orthopedic malpractice suits.

Indications
No consensus has been reached on classification systems, indications for surgery, or a
particular choice of surgery since the orthopedic community first rejected Colles' contention
that all DRFs heal well. Gartland and Werley are generally credited with starting the
revolution in 1951 with their paper examining more than 1000 DRFs, and Jupiter brought the
discussion into the modern era with his 1986 paper in the Journal of Bone and Joint Surgery
that emphasized the importance of reduction.
Despite the large number of papers published each year on DRFs, no consensus has been
reached on treatment, and there is nothing in the literature to suggest that a consensus might
be developing. Indeed, with one approach advocating immediate motion using a fixed-angle
volar plate and another advocating immobilization for 3 months using an internal jointspanning plate, treatment options seem to be diverging rather than converging.
One area of agreement is that fractures in active adults should be reduced anatomically.
Unfortunately, however, no consensus has yet been reached on precisely how the term
"anatomically" should be interpreted. That is, is a 0.5-mm displacement of an intra-articular
fragment "anatomic"? What if it is extra-articular? Is the same definition of "anatomic"
appropriate both for young, active patients and for older, inactive patients?
Even with classification, no consensus has been reached. The International Federation of
Societies for Surgery of the Hand formed a working group of the most distinguished minds in
DRF management to investigate for the existence of a consensus on the best classification
system or, if one did not exist, to develop one. This working group concluded that no
available system was universally useful or accepted and that the group could not develop a
system that would be.
There is, however, a consensus that the goal of treatment is to restore the patient to the prior
level of functioning. This is the starting point for all discussion.

Classification
The goals of any classification system are as follows:

To stratify the injuries

To guide treatment

To facilitate discussion

To predict outcome

Each classification system has its merits and weaknesses with respect to each goal, and often,
more than one classification system is needed. (See the report How to Classify Distal Radial
Fractures.)
The classification systems used most frequently are the Frykman, Melone, AO
(Arbeitsgemeinschaft fr Osteosynthese [Association for the Study of Osteosynthesis]), and
Fernandez systems. Their key characteristics are as follows:

The Frykman classification highlights the injury to the distal radioulnar joint (DRUJ)

The Melone classification, based on the paper by Scheck, highlights the fragmentation
of the articular surface, especially the dorsoulnar corner of the distal radius

The AO classification emphasizes the location as extra-articular, partial articular, and

completely articular

The Fernandez classification is based on the mechanism of injury, deduced from the
displacement of the bone and the location of the fracture lines

A classification system that approaches the topic from another angle categorizes fracture
patterns according to the three-column concept of the wrist and proposes treatment
accordingly. This approach was independently developed by Medoff in 1994 (personal
communication) and by Rikli and Rigazzoni.[4] The three columns are as follows:

Lateral column (the radial half of the radius, including the radial styloid and the
scaphoid facet, though Medoff differentiates these two)

Central column (the ulnar half of the radius, including the lunate facet)

Medial column (the ulna, the triangular fibrocartilage [TFC], and the DRUJ)

Each column is considered separately as to its need for reduction and stabilization. It should
be noted that this conceptual approach does not exclude any other approaches but, rather, is
complementary to them.

The 3-column concept.

Indications for reduction or operative treatment

Most authors advocate an anatomic reduction. This admonition, however, has two problems.
First, not all patients need an anatomic reduction to be able to resume their normal activities.
Second, the concept of "anatomic" reduction is not defined, as noted above. No authorities
advocate operative reduction if the stepoff is 0.5 mm; however, a stepoff of 0.5 mm is
obviously not anatomic. On the other hand, a 20 dorsal tilt is not anatomic, yet inactive
elderly adults can easily return to their previous level of functioning with this alignment.
The indications for reduction or operative treatment are not based solely on age but must be
tailored to the individual patient. It is also important, however, not to err in the opposite
directionthat is, by considering that any patient who is "old" does not require an anatomic
reduction (one paper defined "old" as 50 years old!). Balanced judgment is required.
Most authors would recommend anatomic reduction in a patient who is active in recreation
(remembering that golf and tennis are common activities for persons older than 70 years) or
engages in forceful activities at work. Conversely, if the patient is sedentary, a lesser
reduction may allow return to full activities. Usually, three parameters are relevant:

Intra-articular stepoff - Most authors would accept less than 1 mm of intra-articular

stepoff but not more than 2 mm

Dorsal tilt - Most authors would accept neutral dorsal tilt but not more than 10 (the
range is quite large in the literature, with some authors not accepting more than
neutral)

Radial length - Most authors would accept 2 mm of radial shortening but not more
than 5 mm

Radial tilt is generally considered a lesser parameter.

Defining anatomic reduction in terms of intra-articular stepoff is challenging. The main
challenge lies in making a reliable determination of the relevant parametersthat is, how to
distinguish between less than 1 mm and greater than 1 mm. (See Indications for Reduction in
Distal Radial Fractures.) The difficulty is that opinions are based on studies using routine
plain radiographs, which cannot accurately measure stepoffs with an accuracy of 1 mm.
The threshold of 1 mm for intra-articular displacement is commonly cited, referencing a 1986
landmark paper by Knirk and Jupiter.[5] However, Jupiter has repeatedly stated that this
threshold is not the benchmark that subsequent authors have used, that the 1986 study had
methodologic flaws, and that ligamentous injuries may account for functional limitations
better than intra-articular stepoff does. Surgeons must review the literature with this in mind,
because it changes the reliability of the conclusions reached by many authors after 1986.
Fewer comparative studies (either basic science or clinical) have been published on dorsal
tilt, but this has not kept authors from making pronouncements. The range of anatomic
alignment for dorsal tilt has reportedly been from 0 to 10, with no proviso for less active
patients. Given that a neutral (0) alignment represents an 11 loss of volar angulation, even
the most conservative figure is not truly anatomic.
Commonly, some older, inactive patients are able to achieve full resumption of their activities
with dorsal tilts of 45 or more. Although orthopedic surgeons may find the radiographs of

these patients disturbing and the clinical deformity not much better, some patients are quite
satisfied and able to function in all of their ADLs. This calls into question any rigid threshold
of dorsal tilt, whether it be 0 or 10. Most authors recommend no more than 0-10 of dorsal
tilt in healthy, active individuals.
The basic science of radial length is clear. Shortening radial length by 2 mm doubles the load
through the TFC and the ulna. The clinical relevance of this fact in the context of distal radius
fractures (DRFs) is unclear. Additionally, altering the radius length relative to the ulna affects
the function and forces associated with the DRUJ. On the basis of less well-defined clinical
grounds, most authors would not accept more than 2-5 mm of shortening.
For more information, see Indications for Reduction in Distal Radial Fractures.

Stability of reduction
Another issue that has not been resolved is the stability of the reduction if it is performed in a
closed procedure and without operative support to the fracture fragments. Some authors
believe that a 30 dorsal tilt or any radial shortening will not be stable and will subside. If
function requires that reduction be achieved, surgery is needed to maintain it.
Agreement has been reached that weekly radiographic assessment is required for
approximately 3 weeks. Fractures do not commonly subside after 3 weeks, but this is not a
certainty. Care must be taken to compare the current radiograph with the postreduction
radiograph because subsidence is gradual and can be difficult to detect.

Relevant Anatomy
Treatment depends on a solid understanding of the anatomy of the radius.
On the volar surface of the radius (see the image below), the large lunate facet is seen on the
left, projecting out from the surface of the radius. The volar radial tuberosity is at the right
margin of the bone. The surface is covered with the pronator quadratus (PQ). The cortical
bone is quite thick and is strong, even in osteoporotic patients.

Volar surface.
On the dorsal surface of the radius (see the image below), the Lister tubercle is seen in the
center. This bone is a thin cortical shell, with little structural strength.

Dorsal surface.
The radial surface of the radius is shown in the image below.

Radial surface.
The ulnar surface of the radius, with the sigmoid notch for articulating with the ulna, is
shown in the image below.

Ulnar surface.
On the distal articular surface of the radius (see the image below), the scaphoid facet is to the
right, and the lunate facet is to the left. This bone is the strongest of all the surfaces, and even
if it is osteoporotic, it is quite strong.

Distal surface.
A normal posteroanterior radiograph of the radius is shown in the image below. The ulna is
generally within (plus or minus) 2 mm of the radius.

Posteroanterior radiograph.
A normal lateral radiograph is shown in the image below. Note that the center of the lunate
facet overlies the volar surface of the bone.

Lateral radiograph.
Several anatomic landmarks are important for the volar approach to the radius (see the image
below).

Volar anatomic landmarks important for the volar approach. The

region marked pronator fossa is covered by the pronator quadratus (PQ) muscle. It extends
distally to the PQ line, marked in blue. The watershed line marks the highest crest (most
volarly projecting) surface of the radius. The red X marks the volar radial tuberosity, which
lies just off the pronator quadratus. It is usually not dissected and therefore usually not seen,
but it is easily palpable clinically. VR marks the volar radial ridge.

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