Distal Radius Fracture

Overview

Frykman classification of distal radius fracture (based on joint involvement +/- ulnar styloid fracture)

Classification	Description
Type I	Transverse extra-articular fracture of the distal radial metaphysis
Type II	Type I + ulnar styloid
Type III	Fracture extends into radiocarpal joint
Type IV	Type III + ulnar styloid fracture
Type V	Fracture extends into the distal radioulnar joint
Type VI	Type V + ulnar styloid fracture
Type VII	Fracture extends into both the radiocarpal and distal radioulnar joints
Type VIII	Type VII + ulnar styloid

Eponyms for distal radius fracture

Eponym	Fracture
Colles fracture	Transverse extra-articular distal radius fracture with dorsal angulation of the distal fragment
Smith’s fracture	Transverse extra-articular distal radius fracture with volar angulation of the distal fragment
Chauffer’s fracture	Transverse or oblique fracture of the radial styloid
Dorsal barton	Fracture dislocation of the radiocarpal joint with intra-articular fracture involving the dorsal lip
Volar barton	Fracture dislocation of the radiocarpal joint with intra-articular fracture involving the volar lip
Die-punch fracture	Depressed fracture of the lunate fossa of the articular surface of the distal radius

Distal radius fractures are the most common orthopaedic injury. They commonly occur from fall on an outstreched hand. As with most fractures the have a bimodal distribution with high-energy mechanism in younger patients and low-energy mechanism in older patients. 65% of fractures are extra-articular, 10% are partial articular while 25% are complete.

• Associated injuries
  • Distal radioulnar joint ijury
  • Radial styloid fracture (indicates high enery mechanism
  • Triangular fibrocartilage complex (TFCC) injury
  • Scapholunate ligament injury
  • Lunotriquetral ligament injury
• Indications for operative treatment of distal radius fracture
  • Significantly displaced fractures
  • Comminution
  • Dorsal angulation > 5 degrees or > 20 degrees of contralateral distal radius
  • Displaced intra-articular fracture > 2mm
  • Radial shortening > 5mm
  • Associated ulnar fracture (ulnar styloid does not require fixation)
  • Severe osteoporosis)
  • Articular margin fractures (dorsal and volar Barton’s fractures)
  • Smith’s fractures (comminuted and displaced extra-articular)
  • Die-punch fractures
  • Progressive volar tilt and radial length following closed reduction and casting

Complications of distal radius fractures

Category	Complications
Early	Infection, median nerve compression, complex regional pain syndrome (CRPS), ulnar corner pain and instability, carpal injuries, re-displacement, compartment syndrome
Late	Malunion, delayed union, nonunion, EPL tendon rupture, FPL tendon rupture, carpal instability, osteoarthritis

Dorsal Displaced Fracture (Colles’ Fracture)

A Colle’s fracture is an extra-articular tranverse distal radius fracture with dorsal displacement of the distal fragment.

Colles’ fracture is the most common fracture in elderly individuels (due to post-menopausal osteoporosis)

• Mechanism of injury
  • Fall on outstretched hand (FOOSH): force is applied on the forearm with the wrist in extension causing the bone to fracture at the corticocancellous junction. The distal fragment collpases in extension, dorsal displacement, radial tile and shortening.
• Signs and symptoms
  • Prominence on the dorsal side of the wrist and depression on the volar aspect (dinner-fork deformity)
  • Pain and tenderness on the wrist
  • Pain and tenderness on wrist movement
• Investigations
  • X-ray: may be repeated after 10 – 14 days to ensure the fracture has not slipped.
    • Transverse fracture at the corticocancellous junction (distal radius metaphysis) with dorsal displacement of the distal fragment
    • Impaction of the distal radial fragment
    • May show ulnar styloid fracture
  • CT-scan: to plan treatment
• Conservative treatment
  • Dorsal splint for 1 – 2 days until swelling subsides then cast for 6 weeks: for undisplaced fractures
• Operative treatment
  • ORIF with volar lockng plates
  • Closed reduction and percutaneous pinning (CRPP): for fractures with a stable volar cortex. Kapandji technique.
  • External fixation: for open fractures, highly comminuted fractures or unfit fractures

Volar Displaced Fracture (Smith’s Fracture)

Smith’s fracture is an extra-articular transverse distal radius fracture with volar displacement of the distal fragment.

• Signs and symptoms
  • Garden spade deformity
  • Pain and tenderness on the wrist
  • Pain and tenderness on wrist movement
• Investigations
  • X-ray: may be repeated after 7 – 10 days to ensure the fracture has not slipped.
    • Transverse fracture at the distal radius metaphysis with volar displacement of the distal fragment
• Conservative treatment
  • Cast immobiliation for 6 weeks
• Operative treatment
  • ORIF with a volar plate

Radial Styloid Fracture (Chauffeur’s Fracture)

Chauffer’s fracture is a transverse or oblique fracture extending laterally from the articular surface of the radius.

• Mechanism of injury
  • Historically from the kicking back of a car’s starting handle (crank)
  • Fall on outstretched hand: energy is transferred from the scaphoid to the radial styloid
  • High energy mechansim e.g. motorvehicle accident
• Associated injuries
  • Scaphoid fracture
  • Trans-scaphoid perilunate dislocation
  • Scapholunate ligament rupture
  • Ulnar styloid fracture (Frykman type IV)
• Conservative treatment
  • Closed reduction and cast immobillization
• Operative treatment
  • Closed reduction and percutaneous pinning (K-wire or cannulated percutaneous screw)