Distal End Radius Fracture

Presented by
Dr \ Ahmed Dabour
supervision
Prof.Dr\ Barakat Alalfy
HISTORY
• First surgeon to recognize these injuries was Pouteau in 1783,
although his work was not widely publicized.
• Later Abraham Colles in 1814 gave the classic description of
this fracture.
• Dupuytren brought attention that this is a fracture rather than
a dislocation as it was previously assumed.
• Barton in 1838 described wrist subluxation consequent to
intra-articular fractures of distal radius which could be dorsal or
volar.
• Smith described fracture of distal radius with forward
displacement.
INTRODUCTION
• Distal radius fractures occur through the distal metaphysis of
the radius.
• It may involve the articular surface frequently involving the
ulnar styloid.
• Most commonly results from a fall on the outstretched hand
1. Forced extension of the carpus
2. Impact loading of the distal radius
• Fractures of distal end radius are classified on
the basis of :

Presence or absence of intra-articular involvement .1

Degree of comminution .2
Dorsal or volar displacement .3
Involvement of distal radio-ulnar joint .4
INCIDENCE
Fractures of the distal end radius represent approximately 16% •
.of all fractures treated by orthopaedic surgeons
: There are three main peaks of fracture incidence •
Children aged 5-14 years .1
Males under 50 years (high velocity) .2
Females over 40 years of age (low velocity) .3
Elderly - most commonly extra-articular •
Young - most commonly intra-articular •
Most common risk factors for elderly patients are decreased •
.bone mineral density, female gender & early menopause
ANATOMY
The epiphysis of the distal radius usually •
appears at one year of age, it grows more
in lateral than medial direction and forms
the radial styloid process and three
articular facets (scaphoid, lunate and
sigmoid notch). Distal radius fuses with
diaphysis at 17 years of age in females
.and 19 years in male
The metaphysis is flared distally in both •
the AP and the lateral planes with thinner
cortical bone lying dorsally and radially.
The significance of the thinness of these
cortices is that the fractures typically
.collapse dorso- radially
• In the anteroposterior plane the strongest bone is found under
the lunate facet of the radius. The line of force passes down the
long finger axis through the capito-lunate articulation and
contacts the radius at this location.

• The "palmar ulnar corner" is often referred to as the keystone of

the radius. It serves as the attachment for the palmar distal
radioulnar ligaments and also for the stout radiolunate ligament.
Displacement of this fragment is associated with palmar
displacement of the carpus and also with loss of forearm
rotation.
The medial aspect of distal •
radius is triangular and presents
an articular facet at its distal end
which is concave and is called
sigmoid notch, which articulates
with the convex head of the
distal ulna. The origin of TFCC
attaches to the distal border of
.sigmoid fossa
TFCC is the main stabilizer of •
distal radioulnar joint in addition
to contributing to ulnocarpal
.stability
The dorsal aspect of the distal radius •
.is narrower than the volar aspect

The most prominent 'V' shaped •

crest on the dorsal aspect is called
.lister's tubercle

In axial loading, radius bears 80% of •

the load and ulna bears 20% of the
.load
LIGAMENTOUS ANATOMY
Extrinsic ligaments around •
the distal end radius play an
important role in closed
reduction of the fractures
.(Ligamentotaxis)
The palmar extrinsic •
ligaments are attached to
the distal radius, and it is
these ligaments that are
relied on to reduce the
components of a fracture
.using closed methods
Applied anatomy
Jacob and his co-authors interpreted the wrist as consisting of three distinct ⚫

columns, each of which is subjected to different forces and thus must be

addressed as discrete elements
 The radial column, or lateral column

The radial column consists of

the scaphoid fossa and the
radial styloid. Because of the
radial inclination of 22
degrees, impaction of the
scaphoid on the articular
surface results in a shear
moment on the radial styloid
causing failure laterally at the
radial cortex. The radial
column, therefore, is best
stabilized by buttressing the
lateral cortex
 The intermediate column

The intermediate column consists of

the lunate fossa and the sigmoid
notch of the radius. The intermediate
column may be considered the
cornerstone of the radius because it is
critical for both articular congruity
and distal radioulnar function. Failure
of the intermediate column occurs as
a result of impaction of the lunate on
the articular surface with dorsal
comminution. The column is stabilized
by a direct buttress of the dorsal ulnar
aspect of the radius
 The medial column

The ulnar column consists of the

ulna styloid but also should include
the Triangular fibrocartilage complex
[TFCC] and the ulnocarpal ligaments
 DIAGNOSIS
.There is usually a history of fall on out-stretched hand •
.Wrist is typically swollen with ecchymosis and is tender •
Visible deformity of the wrist with hand most commonly displaced in •
.dorsal direction
Adequate and accurate assessment of the neurovascular status of •
.the hand is performed before any treatment is given out
.Radiograph of the wrist are taken in AP, Lateral & Oblique views •
CT scan of wrist can be done to see the extent of intra-articular •
.involvement & communition
 SOME IMPORTANT MEASUREMENTS
• Distal radio-ulnar joint congruity can be seen by the
following measurements :

1. Palmar tilt-normal range is 11 to 12 degrees

2. Radial inclination - normal range is 20 to 23 degrees
3. Ulnar variance - normal range is 0 to -2mm
4. Radial length normal range is 10 to 12 mm
5. Carpal mal-alignment
Volar / Palmar Tilt )1
On a true lateral view a line is drawn connecting the most distal points •
of the volar and dorsal lips of the radius. The volar or palmar tilt is the
angle created with a line drawn perpendicular to the longitudinal axis of
.the radius
Radial Length / Height )2

Radial length is measured on the AP radiograph as the distance •

between one line perpendicular to the long axis of the radius
passing through the distal tip of the radial styloid & second line
.intersects distal articular surface of ulnar head
Ulnar Variance )3
This is a measure of radial shortening and should not be confused with •
measurement of radial length. Ulnar variance is the vertical distance between
a line parallel to the medial corner of the articular surface of the radius and a
line parallel to the most distal point of the articular surface of the ulnar head,
both of which are perpendicular to the long axis of the radius Ulnar Variance
Radial Inclination )4
On the AP view the radius inclines towards the ulna. This is
measured by the angle between a line drawn from the tip of the
radial styloid to the medial corner of the articular surface of the
radius and a line drawn perpendicular to the long axis of the
.radius
Carpal Malalignment )5
• On a lateral view one line is drawn along the long axis of the capitate and
one down the long axis of the radius. If the carpus is aligned, the lines will
intersect within the carpus. If not, they will intersect outwith the carpus
Line along the long axis of capitate
 INDICATORS OF INSTABILITY
GREATER THAN 2mm articular step-off •
degrees of dorsal tilt 10> •
15radial inclination< ⚫
loss of radial hight > 5mm •
Comminution of one cortex across midaxial line of lateral xray •
Commination of both dorsal palmar cortices •
Irreducible fracture •
.Loss of reduction after attempt to reduce •
 CLASSIFICATION

There is perhaps no other fracture in the orthopedic •

literature that has garnered so many eponyms over time
.than fractures of the distal radius
:Various eponyms are •
Colle's fracture .1
Smith's fracture .2
Barton's fracture .3
Chauffer's fracture / hutchinsons fracture .4
Die punch fracture/lunate load fracture .5
 Colle's fracture
It is an extra-articular fracture occurs at cortico-cancellous junction of distal end ⚫
of radius within 2cm from the articular surface

.The distal fragment is usually displaced dorsally •

It may extend into DRUJ with six displacements •

• Impaction
• Lateral displacement
• Lateral rotation (angulation)
• Dorsal displacement
• Dorsal rotation (angulation)
• Supination.

It may often accompany fracture of the ulnar styloid which signify avulsion of the TFCC and ⚫
ulnar collateral ligaments
 Smith's fracture/Reverse colle's
Occurs at the same level on the •
.distal radius as a colles' fracture
Distal fragment displaced in •
palmar (volar) direction with a
."garden spade" deformity

Smith's fracture typical •

:deformity
Dorsal prominence of the distal end .1
of the proximal fragment
Fullness of the wrist on the volar .2
side due to the displaced distal
fragment
Deviation of the hand toward the .3
radial side
 Barton's fracture
It is an intrarticular fracture dislocation or subluxation •
in which the rim of the distal radius dorsally or volarly is
displaced with the hand and carpus

There are 2 types •

Dorsal barton
volar barton
 Chauffeur's fracture/hutchinson fracture
It is an intra-articular fracture involving •
the radial styloid, the radius is cleaved in
a sagittal plane and the fragment is
.displaced proximally
Isolated fracture of the radial styloid •
are fairly common from backfiring of
starting handle of car
 Lunate load/Die punch fracture
It is an intraarticular fracture with displacement of the •
medial articular surface which usually represents a
depression of dorsal aspect of lunate fossa
:Ideal classification system should describe •

Type of injury •

Severity •

Evaluation •

Treatment •

Prognosis •
 Common Classifications
Gartland & Werley .1
Frykman (radiocarpal & radioulnar) .2
AO .3
Melone (impaction of lunate) .4
Fernandez (mechanism) .5
 Gartland & Werley
Simple Colles fracture without intrarticular involvement .1
Comminuted Colles' fractures with intra-articular extension without displacement .2
Comminuted Colles' fractures with intra-articular extension with displacement .3
Extra-articular, undisplaced .4
 Melone's classification
Type I : Stable fracture without displacement. This
pattern has characteristic fragments of the radial
.styloid and a palmar and dorsal lunate facet
Type II : Unstable "die punch" with displacement
of the characteristic fragments and comminution
of the anterior and posterior cortices
Type IIA : Reducible
Type IIB : Irreducible (central impaction fracture)
Type III: "Spike" fracture. Unstable. Displacement
of the articular surface and also of the proximal
spike of the radius
Type IV : "Split" fracture. Unstable medial complex
that is severely comminuted with separation and
or rotation of the distal and palmar fragments
Type V : Explosion injury
 Classification - Fernandez (1997)
Bending- metaphysis fails under .1
tensile stress
Extra-articular )Colles, Smith(
Shearing-fractures of joint surface .2
Intra articular (Barton, radial styloid)
Compression intraarticular fracture .3
with impaction of subchondral and
metaphyseal bone (die-punch)
Complex articular fracture & radial
pilon fracture
Avulsion- fractures of ligament .4
attachments (ulna, radial styloid)
Combined complex - high velocity .5
injuries
 Goals of treatment
• Preserve hand and wrist function
• Realign normal osseous anatomy
• promote bony healing
• Avoid complications
• Allow early finger and elbow ROM
 RATIONALE FOR TREATMENT
The goal of treatment of these fractures is a
wrist that provides sufficient pain-free motion
and stability to permit vocational and daily
activities in all age groups without the
propensity for future degenerative changes in
the young
 Options for Treatment
Casting .1
External Fixation .2
Joint-spanning ⚫
Non bridging •
Percutaneous pinning .3
Internal Fixation .4
Dorsal plating •
Volar plating •
Combined dorsal/volar plating •
focal (fracture specific) plating •
Indications for Closed Treatment

Low-energy fracture
Low-demand patient
Medical co-morbidities
Minimal displacement- acceptable alignment
Technique of Closed Reduction
Anesthesia (pain relief & decrease muscle spasm)
Hematoma block •
Intravenous sedation •
Bier block •
Traction: finger traps and weights or manual traction
:Reduction Maneuver (dorsally angulated fracture)
,hyperextension of the distal fragment ⚫
Correct radial tilt ⚫
Maintain weighted traction and reduce the distal to the proximal fragment with •
.pressure applied to the distal radius
Apply well-molded splint or cast, with wrist in neutral to
slight flexion. Do check X-ray to confirm the acceptable
.reduction
Post reduction management
Take x-ray immediately after the application of the cast. If .1
reduction is not satisfactory, another attempt to achieve accurate
.reduction should be made
If there is any circulatory embarrassment, split the cast along .2
.the dorsum of its entire length
Elevate the arm with the fingers pointing towards the ceiling .3
.for the first 48 hrs
Take x ray again on the 5th and 10th days, check for .4
.maintenance of position
Institute physical therapy, heat, gentle massage, water massage .5
.and active exercises for the fingers, elbow and shoulder
:Exercise programme
Maximum extension of all digits )1
Opposition of the thumb )2
The grasp or fist exercise with all finger flexing to the palmar )3
creases or as near as possible to it
The claw exercise with the MCP joint of the fingers kept )4
extended but the IP joint maximally flexed
The table top exercise with the MCP joint maximally flexed but )5
the IP joint extended
Abduction and adduction of all fingers )6
Plus use shoulder and elbow is a must )7
Complications

Failure or loss of reduction •

Skin complications •
Tendon adhesions and entrapement •
Carpal tunnel syndrome due to excessive palmar flexion •
Nerve complications •
Vascular injury •
Indications for Surgical Treatment

High-energy injury with instability .1

Comminuted displaced intraarticular fracture .2
Open injury .3
Radial inclination < 15> 2mm .4
Dorsal tilt > 10° .5
DRUJ incongruity .6
Failed closed reduction .7
Percutaneous direct pinning.1
Aim of this procedure is to fix the mobile fragment to the opposite cortex •
proximal to the fracture
Direct pinning of the fragments especially the intermediate column through •
the distal ulna add stability to the DRUJ and medial half of articular surface
Application is extra focal where entry point of k wire is away from fracture •
site mainly 2 types
a)transulnar
b)transradial
Indications-a) nonarticular displaced b)articular nondisplaced c)articular •
displaced, all of which are reducible and stable after reduction
Contraindications are severe osteoporosis, severe communition , soft tissue •
interruption and chauffer fracture
AFTERTREATMENT

The arm is immobilized in a cast below the elbow with

the forearm and wrist in neutral position. The Kirschner
wires that have been cut off just beneath the skin are
removed at 6 weeks. The wrist is supported with a
removable static splint, and gradual range-of-motion
exercises are permitted
Kapandji technique of intrafocal pinning with.2
pins for nonarticular fracture
In intrafocal pinning a smooth k-wire is inserted after a manual •
reduction , through a short skin incision, directly into the
fracture line
Secondary displacement is made impossible by immediate •
contact of the distal fragment with the arum nut of the pins
which are working as an abutement,not as a resistant
component
 Exfixation ternal.3

Two types of external fixation •

Spanning external fixation )1
Non-spanning external fixation )2
 Spanning (Ligamentotaxis)
A spanning fixator is one which fixes ⚫
distal radius fractures by spanning the
carpus; I.e., fixation into radius and
metacarpals
Bridging external fixation allows •
distraction across the radiocarpal joint
.and directly neutralizes axial load
Ligamentotaxis of the fracture•
fragments
Adjunctive fixation and supplemental•
.bone grafting results in earlier union
 Non-spanning

A non-spanning fixator is one which •

fixes distal radius fracture by securing
pins in the radius alone, proximal to and
.distal to the fracture site
Indication extra-articular or minimal•
intra- articular dorsally displaced
fractures with metaphyseal instability
Contraindication: lack of space for pins•
in the distal fragment. 1 cm of intact
volar cortex required for purchase of pins
Complications
Complication rates are high
Pin tract infection •
RSD Finger stiffness •
Loss of reduction; early vs. late•
Tendon rupture •
Open Reduction and Internal Fixation
Open reduction of articular fractures of the distal radius is
indicated in active patients with good bone quality when
anatomic restoration of the joint surface cannot be achieved by
closed manipulation, ligamentotaxis, or percutaneous reduction
maneuvers or as an alternative to percutaneous fixation at the
.preference of the patient or surgeon
Dorsal plating
Internal fixation using a dorsal plate has several theoretical •
.advantages
Technically familiar to most surgeons, the approach avoids the •
.neurovascular structures on the palmar side
Further, the fixation is on the compression side of most distal •
.radius fractures and provides a buttress against collapse
Initial reports of the technique demonstrated successful •
outcomes with the theoretical advantages of earlier return of
function and better restoration of radial anatomy than was seen
.with external fixation
However, there were increasing reports of extensor tendon•
ruptures because of prominent hardware, particularly at Lister
.tubercle
The more distally the plate is applied on the dorsum of the•
wrist, the more proximally the distal screws need to be directed
.to avoid articular penetration
This oblique orientation of the screws allows the distal fragment•
.to displace palmary
The palmar displacement of the fragment is particularly•
problematic because it results in
incongruity at the distal radioulnar joint and )1(
prominence of the hardware dorsally with the tendency for )2(
extensor tenosynovitis or tendon rupture
Operative Technique
A longitudinal incision is centered over the fracture in line with the ulnar •
.aspect of Lister tubercle
The extensor retinaculum is incised in a z-plasty manner that allows for one •
limb to be placed over the plate and the second limb to be repaired over the
extensor tendons to prevent bow-stringing of the tendons with wrist
.extension
The extensor policies longus tendon is dislocated from its position at the •
.tubercle and sub periosteal dissection is performed radially and ulnarly
Care should be taken to preserve all of the dorsal fragments for re- •
.establishment of radial length
Traction is then applied by either an assistant or by the use of finger traps •
.with weights suspended off the end of the table
Care should be taken to ensure that the hand is not pronated relative to the ⚫

.forearm
Complications

Because of direct contact with the dorsal plate

Irritation •
Synovitis •
Attrition •
Tendon rupture •
Volar Plate Fixation
Regardless of the displacement of the distal fragment
(dorsal, volar, radial), volar plating of both articular and
nonarticular fractures is an effective fixation method that
may reduce some of the soft tissue complications
associated with dorsal plating. Advantages of palmar
exposure and volar plating include the following
Operative technique
Palmar plates may be applied through either a flexor carpi •
radialis (FCR)/radial artery interval or through a midline flexor
tendon/ulnar neurovascular bundle interval. The FCR/radial
artery approach is preferable for
fixation of dorsally displaced fractures with dorsal comminution and )1(
.fixation of partial articular fractures (articular shear fractures) )2(
The skin incision is centered over the FCR, with care being taken
to avoid injury to the palmar cutaneous branch of the median
nerve that lies ulnar to the tendon. The radial artery is mobilized,
and dissection is carried radially by releasing the brachioradialis
.tendon from the radial styloid
The second surgical approach to the palmar radius is the flexor
tendon/ulnar neurovascular bundle interval. The skin incision is centered
over the ulnar border of the palmaris longus, the flexor tendons are
mobilized radially, and the ulnar neurovascular bundle is taken ulnary.
With this approach the pronator quadratus is released from the ulna. The
incision may be extended distally to release the transverse carpal
ligament, particularly if the patient had any median nerve symptoms
preoperatively. This incision is preferred when the majority of the
.comminution is at the palmar lunate facet
ADVANTAGES
Minimal volar comminution facilitates reduction of dorsally displaced •
.fractures
Anatomic reduction of the volar cortex facilitates restoration of radial . •
.length, inclination, and volar tilt
Avoidance of additional dorsal dissection helps preserve the vascular supply •
of comminuted dorsal fragments
Because the volar compartment of the wrist has a greater cross-sectional •
space and the implant is separated from the flexor tendons by the pronator
.quadratus, the incidence of flexor tendon complications is lessened
The use of fixed-angle volar plate designs avoids screw "toggling" in the •
distal fragment and thus reduces the danger of secondary displacement
When stabilized with a fixed-angle internal fixation device that uses •
subchondral pegs or screws, control of shortening and late displacement of
articular fragments are improved and the need for bone grafting reduced
 Complications

Locking plates is the potential for articular penetration with distal •

plate position on the palmar surface of the radius

Collapse of the fracture also can lead to joint penetration by the •

distal screws especially in osteopenic patients

Extensor tendon problems can be caused by penetration •

 Complications of Distal radius fractures

Chronic Regional Pain Syndrome )1

Nonunion )2
Nonunion of distal radius fractures is rare but presents unique ⚫
treatment challenges because of the associated pain, joint
contractures, tendon imbalance or rupture, and occasional
severe bony deformity
nonunion of ulnar styloid process fractures in conjunction with •
distal radius fractures is quite common and yet is rarely
symptomatic
Treatment of distal radius nonunion must be individualized and •
based on the patient's symptoms, functional deficit, and bony
substance
 Mal-union )3
Nerve Injuries )4
Tendon rupture )5
Loss of range of motion )6
THANK
YOU