4/5/2020 Distal Radius Fractures – RP's Ortho Notes

RP's Ortho Notes

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Distal Radius Fractures

Surgical Anatomy

The distal radius has metaphyseal flare and three articular surfaces: scaphoid fossa, lunate fossa and
the sigmoid notch. The dorsal and radial cortices are thin and the volar and ulnar cortices are thick:
this explains the greater incidence of dorsal and lateral comminution and collapse. The volar surface
is separated from the flexor tendons and median nerve by the pronator quadratus. Just beyond the
distal edge of pronator quadratus the volar surface slopes distally and dorsally. This demarcation is
called the watershed line. Volar plates should not be placed beyond this line as it would project
anteriorly and also lack the coverage by pronator quadratus and cause flexor tendon irritation.

Volar ligaments are a ached to the volar rim. In between the volar ligaments and pronator quadratus
lies the intermediate fibrous zone. Elevation of pronator quadratus with 1-2mm cuff of intermediate
fibrous zone makes its repair easy. At the lateral edge of volar surface lies the radial septum, which
gives insertion to the brachioradialis. Brachioradialis is step-cut in extended flexor carpi radialis
approach to access the dorsal surface in complex intra-articular fractures of distal radius. The volar
ligaments are short, stout and stronger while the dorsal ligaments are thinner and arranged in zigzag
pa ern, hence the volar ligaments become tensioned before the dorsal ligaments leading to dorsal
tilting of the articular surface. Palmar ulnar corner is called the keystone of distal radius. It is the
strongest and supports the lunar facet. It gives a achment to volar ligaments.

Biomechanics

Jacobs interpreted the wrist as having three columns each subjected to different mechanical forces
and having discrete elements. Radial column is formed by the scaphoid fossa and the radial styloid.
Due to thin cortex radially it shortens and tilts laterally after fracture which is best addressed by
bu ressing the altars cortex. Intermediate column composed of lunate fossa and sigmoid notch is the
corner stone of distal radius. It usually fails in impaction and needs elevation and stabilisation. Ulnar
column is ulna and TFCC complex.

Epidemiology

Distal radius fractures sha er the mechanical foundation of the most elegant tool humans have; the
hand. One sixth of all fractures seen in emergency room. Most common fracture between 15-75 years.
Three main peaks of fracture distribution are seen with three distinct groups: paediatric group
between age 5-14, makes under 50 years and females after the age of 40 years. The first and last
groups represent insufficiency fractures and the middle one represent traumatic fractures. Distal
radius fracture is the most common osteoporotic fracture.

Classification

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4/5/2020 Distal Radius Fractures – RP's Ortho Notes

Various classification systems available for distal radius fractures. Due to the large number of
variables to consider and the broad spectrum of injuries no classification is adequate. Most
classifications are based on location of fracture, number of intra-articular fragments, direction of
displacement and involvement of ulna. A good classification should categorise the fracture type and
injury severity to guide treatment.

In 1951, Gartland and Werley published a detailed evaluation and classification system based on
metaphysical comminution, intra-articular extension and displacement. In 1959 Lidstrom outlined a
classification based on fracture line, direction and degree of displacement, extent of articular
involvement and involvement of DRUJ. In 1965, Older proposed a classification that incorporated
radial shortening as variable that determine the type. In 1967, Frykman identified the importance of
ulnar involvement and publish a classification based on involvement of radiocarpal and radioulnar
joints and the ulnar styloid fracture. In 1984, Melone heralded the contemporary era of classification
by stressing the careful delineation of 4 components of radio carpal joint namely radial shaft, styloid,
dorsal medial and volar medial fragments. Other modern classifications are Universal classification
by Cooney, Mayo clinic classification and AO classification.

In 1993, Fernadez classification was introduced, which was designed to be practical, determine
stability, include associated injuries and provide general treatment recommendations. It identified
fracture pa erns that reflect specific mechanisms of injury. There were 5 types. 1- Bending, 2- Shear,
3- Compression, 4- Avulsion and 5- Combined.

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4/5/2020 Distal Radius Fractures – RP's Ortho Notes

Management

Treatment plan for distal radius is determined by patient factors, fracture pa ern, fracture stability
and associated injuries.

Patient factors include age, lifestyle, mental status, associated medical conditions and treatment
compliance.

The course of treatment is decided by several variables which can be broadly divided into patient
factors, fracture displacement, fracture stability and associated factors. The important questions to
ask are 1) Is the fracture displaced or undisplaced 2) Is the fracture intra or extra articular 3) Is it
reducible or irreducible 4) Is it stable or unstable.

Radiological Assessment

Most important variable with regard to fracture pa ern is whether the fracture is intra-articular or
extra-articular. In extra articular fractures, successful outcome needs restoration of certain parameters
like radial length, radial inclination and palmar tilt. In intra-articular fractures in addition to the
above articular congruity must be restored.

Palmar tilt is measured on the lateral view as the angle between the line connecting the most distal
point of volar and dorsal lip of radius and another line drawn perpendicular to the longitudinal axis
of radius. Normally palmar tilt is about 11 degrees. Distance in millimetres between a line drawn
perpendicular to the radius longitudinal axis at the level of tip of styloid and a similar line drawn at
the level of ulnar articular surface is the radial length. Normally is is about 11 mm.

Radial inclination is the angle between a line drawn connecting the tip of styloid and the ulnar corner
of radial articular surface and a line perpendicular to the long axis of radius at the level of tip of
styloid. Ulnar variance is the vertical distance in millimetres between the medial corner of radius and
the most distal point on the ulnar articular surface. Carpal malalignment is assessed by the angle
subtended by the longitudinal axis of capitate and radius. If the lines intersect within the carpus there
is no malignment if outside there is malalignment.

Assessment of reduction

Acceptable reduction means >15 radial inclination, < 5mm radial shortening, <15 dorsal and <20
palmar tilt, ulnar variance negative or neutral, articular gap should be less than 2mm and the
articular step <1mm. Standardised PA and lateral views and some times comparative views of
opposite wrist are needed for accurate evaluation of these parameters. CT with 3D reconstruction is
useful in complex injuries. Acceptable reduction range is also influenced by the physiological health
of patient and functional demands of the patient.

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