Fractures of the Distal Radius - Punjab Orthopaedic Association

Fractures of the distal radius: Current Concepts
P. P. Kotwal MS, Bhavuk Garg MS
Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi
34
ractures of the Distal radius account for 14% of all
extremity fractures and 17% of all fractures treated in
Fthe emergency department. As life expectancy
increases, the incidence of distal radial fractures can be
1
expected to increase as well .
There appears to be a bimodal distribution of distal radial
fractures consisting of a younger group who sustains
relatively high-energy trauma to the upper extremity and an
elderly group who sustains both high-energy injuries and
insufficiency fractures. In older age groups, more women
have fracture of the distal radius than men. The relationship
between distal end radius fracture and osteoporosis has been
established. Currently, World health organization advises that
a fracture of distal end radius in a postmenopausal woman is
an indication for evaluation of bone mineral density (BMD).
As the population is aging and also activity level of older
population is also on increase, the presence of osteoporosis or
osteopenia places this population at a much higher risk for
2-4
fractures of the distal radius .
Distal end radius fractures (Fig. 1) in younger population
are usually result of high energy injuries and represent a
different subset of fractures, often with resultant significant
injury to upper extremity and sometimes with multiple
associated fractures. These fractures usually have a high
degree of comminution, instability and associated soft tissue
5
injury as well .
There seems to be a growing incidence of these fractures
in both groups, with sharpest increase seen in both elderly
females and younger adult males. There is also a difference in
mechanism of injury between the groups. The majority of
fractures in older population are result of fall, while in
younger age group, these fractures are usually secondary to
motor vehicular accidents and sports.
Surgical anatomy
The distal aspect of the radius functions as an articular
foundation of the wrist joint. At the metaphyseal flare, the
thickness of the cortical bone decreases and the amount of
cancellous bone increases, forming a zone predisposed to
6
fracture . The distal end of the radius has three concave
articular surfaces—the scaphoid fossa, the lunate fossa, and
the sigmoid notch. These areas of bony thickening direct the
dissipation of energy delivered to the wrist and account for the
frequently seen fractures occurring between scaphoid and
lunate facets of the radius. The articular surface of the distal
aspect of the radius tilts 21 degrees in the anteroposterior
5
plane and 5 to 11 degrees in the lateral plane . (Fig. 1)
A three column theory has been proposed for distal end
radius, that the distal part of the radius consists of a medial, an
intermediate, and a lateral column. This theory emphasizes
that (1) the lateral, or radial, column is an osseous buttress for
the carpus and is an attachment point for the intracapsular
ligaments; (2) the intermediate column functions in primary
load transmission; and (3) the medial, or ulnar, column serves
as an axis for forearm and wrist rotation as well as a post for
7
secondary load transmission .
The triangular fibrocartilage (TFCC) extends from the
rim of the sigmoid notch of the radius to the ulnar styloid
process. Fracture of the ulnar styloid, particularly at base, may
represent instability of distal radio-ulnar joint (DRUJ). Only
the brachioradialis tendon inserts onto the distal aspect of the
radius; the other tendons of the wrist pass across the distal
aspect of the radius to insert onto the carpal bones or the bases
of the metacarpals. In addition to the extrinsic ligaments of the
wrist, the scapholunate interosseous and lunotriquetral
interosseous ligaments maintain the scaphoid, lunate, and
triquetrum in a smooth articular unit that comes into contact
with the distal aspect of the radius and the triangular
5
fibrocartilage complex .
Fig 1
Correspondence :
P. P. Kotwal,
Professor & Head,
Department of Orthopaedics,
All India Institute of Medical Sciences
e-mail :prakash_kotwal@hotmail.com

Pb Journal of Orthopaedics Vol-X, No. 1, 2008
Fractures of the Distal Radius: Current Concepts 35
Classification
A number of authors have proposed systems for the
classification of fractures of the distal aspect of the radius
including those described by Frykman, Melone, and the AO
group. The exact location of fracture lines reflected in the
Frykman classification communicates little useful
information about fracture severity or displacement.
The AO classification is the most detailed and inclusive
9
system . AO type-A fractures (extraarticular) are usually
bending injuries through the metaphysis, and they do not
affect the articular surface of either the radiocarpal or the
radioulnar joint. AO type-B fractures (partial intraarticular)
result from shear or impaction injuries, causing fractures of
the volar and dorsal rims, fractures of the radial styloid or
medial corner, or die punch fractures of the central articular
surface. A portion of the articular surface remains in
continuity with the metaphysis, which adds greatly to the
stability of the fracture. AO type-C fractures (complex
articular) are generally high-energy fractures, often involving
a combination of shear and impaction. None of the articular
surface remains in continuity with the metaphysis.
Comminution of the distal radial metaphysis can be present in
many of these injuries. It is defined as involvement of >50%
of the diameter of the metaphysis as seen on any radiograph,
comminution of at least two cortices of the metaphysis, or
>2.0 mm of shortening of the radius.
5
The Universal Classification of distal radial fractures
was proposed in 1990. This system differentiates between
extra-articular and intra-articular fractures, as well as
between stable and unstable fractures; it was created as a
treatment-based algorithm.
Classification Description
I
Nonarticular, nondisplaced
II Nonarticular, displaced
A Reducible, stable
B Reducible, unstable
C Irreducible
III Articular, nondisplaced
IV Articular, displaced
A Reducible, stable
B Reducible, unstable
C Irreducible
D Complex
Table 1: Universal Classification of fractures of distal end radius
History and Physical Examination
Comprehensive initial evaluation of the patient who has
sustained a radius fracture is vital to successful treatment. Not
only is the mechanism of injury important, but the patient's
medical and social history also can affect treatment decisions.
A careful physical examination is important as well; the initial
evaluator should not be so focused on the radius that he or she
underestimates concomitant conditions such as injuries about
the elbow or acute neurologic compromise. It is important that
this initial examination includes the history of the injury to
assist in determining the degree of energy involved. The
carpus should be examined for fractures or fracturedislocations.
Vascular compromise occurs rarely, but
neurological lesions are relatively frequent. Nerve injuries
usually involve the median nerve, but can also involve the
ulnar or radial nerves. If patients do not experience
improvement of sensibility after reduction or if sensibility
worsens over serial examinations, one should suspect carpal
tunnel syndrome, investigate accordingly and if confirmed,
5, 10
proceed with an urgent carpal tunnel release .
Radiographic examination
Preoperative planning is of vital importance to
successful surgery, and adequate radiographic views of the
wrist are required. Posteroanterior (PA), lateral, and oblique
radiographs of the injured forearm with wrist should be
obtained. Oblique views reveal intra-articular involvement
that is not apparent on the other views. The semisupinated,
oblique view demonstrates the dorsal facet of the lunate fossa,
whereas the partially pronated, oblique PA view allows
5, 11-13
visualization of the radial styloid .
The fractures of the distal radius can be associated with
fractures of the ulna and related ligamentous or bony injuries,
which can be occult, an evaluation of the soft tissues of the
distal forearm is important. For this assessment, 2 fat planes
on the lateral view and 5 fat planes on the PA view are useful.
On the lateral view, the deep fat pad of the pronator quadratus
and the dorsal skin subcutaneous fat line can be seen in
relation to the distal radius. The deep fat pad of the pronator
quadratus forms a slight, ventral concave line. This is
convexly bowed in a ventral direction or completely absent in
pathologic conditions. The dorsal skin subcutaneous fat line is
flat or is a dorsal concave line. It is abnormal when it is convex
in the dorsal direction. The PA view shows the thenar,
hypothenar, pararadial, and paraulnar skin subcutaneous fat
lines and the deep, navicular fat pad. Swelling that is not
associated with an observed fracture should initiate a search
for an additional abnormality.

Kotwal et al.
36
Evaluation of the intra-articular extent of the fracture is
crucial. Knirk and Jupiter found that 2.0 mm or greater of
distal radial articular displacement can lead to posttraumatic
14
arthrosis .
Post reduction radiographs help to identify the residual
deformity and the degree of comminution. Standard
posteroanterior traction radiographs help in determining
whether the fracture is intra-articular or extraarticular and
may also demonstrate the presence of associated
intracapsular or interosseous carpal ligament injuries. The
important radiographic determinations are radial inclination
(23°), radial height (12 mm), volar tilt (11°), reduction of the
distal radioulnar joint, and radial width (normally within 1
11- 13
mm of that of the contralateral side) . Computed
tomography should be performed when conventional
radiographs provide insufficient detail and, specifically, when
a detailed evaluation is needed of the radiocarpal articular
step-off and gap displacement—factors that are crucial in
predicting the development of radiocarpal osteoarthritis.
Computerized tomography is also helpful in determining the
operative approach and the fractures of the lunate facet. CT
scan proves useful in evaluating volar or dorsal displacement
of the radial styloid process that is not evident on plain
5, 8-9
radiographs, especially if the wrist is in a cast.
Management
The fracture pattern, degree of displacement of the fracture
fragments, and stability of the fracture determine whether
surgical treatment rather than immobilization in a cast is
15 16
needed. Trumble et al and Fernandez et al showed that even
step-offs or gaps of 1 mm affected outcome. In selecting
treatment, therefore, a technique should be used which makes
alignment of articular surfaces a priority.
Although restoration of palmar tilt to preoperative values is
not critical, restoration to neutral is advised for a number of
reasons. First, this will more adequately restore radial length
and avoid ulnar impaction or distal radioulnar joint
incongruity. Second, it will prevent subsequent problems with
midcarpal instability. Similarly, correction of radial tilt,
although not absolutely critical, will restore more normal
joint mechanics. Radioulnar length, however, must be
restored with little compromise because limitation in
pronation and supination and ulnar impaction are late causes
17-18
of pain and impairment .
Closed reduction versus open reduction
Fractures with loss of 2 mm of radial height, change in radial
inclination of 5°, loss of volar tilt of 10°, loss of reduction
of the distal radioulnar joint, and/or those with >1 to 2 mm of
intra-articular step-off should be reduced. Surgical
intervention is considered when an acceptable reduction
cannot be achieved or maintained by closed means in addition
to achieving an anatomic reduction, establishing stable
fixation to allow early motion and rehabilitation should be the
5, 8-9
goal .
It is critical that intercarpal intervals and relationships,
the carpal bones themselves, and the distal radioulnar joint be
assessed on preoperative radiographs and by physical
examination when distal radius fractures are treated.
Scaphoid fractures require internal fixation, if the
displacement exceeds 1 mm, and scapholunate dissociation
must be anatomically reduced and pinned. Distal radioulnar
joint subluxation should not be attributed to radiograph
projection, and its stability must be assessed clinically. If
associated with a displaced ulnar styloid fracture, reduction
and fixation may be necessary to restore stability by the
insertion of the triangular fibrocartilage complex (TFCC).
Intercarpal ligamentous injury is common with both
extraarticular and intraarticular distal radius fractures, but in
most cases, these will heal. If intercarpal or ulnar wrist pain
persists after fracture union, however, arthroscopy and/or
magnetic resonance (MR) imaging may be indicated.
A balance then between achieving anatomic reduction,
securing stable fixation, minimizing soft-tissue disruption,
and allowing early rehabilitation should be the rationale for
choosing between closed reduction and open reduction.
5, 8-9
Closed reduction
Closed reduction and cast immobilization (Fig 2) is still
the mainstay of treatment for nondisplaced, stable fractures.
In an attempt to prevent displacement of the reduced fracture
during immobilization in a splint or plaster cast, placement of
the wrist in the extremes of positions has been used in the past.
This can lead to median nerve compression and stiffness of
the fingers and wrist.
Theoretically, a long arm thumb spica splint with the
forearm in supination and the thumb interphalangeal joint free
is used for the first week and changed to a circular cast the
second and third week. The forearm is supinated to overcome
the pull of brachioradialis and a thumb spica is worn to
prevent the irritation of the radial sensory nerve by the leading
edges of the cast that do not include the thumb. However, in
our practice, thumb spica is not given and we have not seen
any complication related to it. The wrist is maintained in a
neutral position through out treatment. A short arm cast is
worn during weeks 3 through 6. If closed treatment is chosen,
weekly or biweekly radiographs are imperative.

Pb Journal of Orthopaedics Vol-X, No. 1, 2008
Fractures of the Distal Radius: Current Concepts
37
The pins-and-plaster technique, although appealing in
concept, it is often difficult in practice. Application of the
plaster around the pins may prolong the procedure
sufficiently to prevent adequate molding of the cast.
Subsequent dorsal redisplacement and angulation of the distal
fragment has been one reason that the pins-and-plaster
19-22
technique is now infrequently used .
23-28
Percutaneous pinning
Various configurations of percutaneously placed pins
have been advocated for the stabilization of distal radius
fractures. This technique has been used for displaced extraarticular
fractures with or without dorsal comminution, early
loss of reduction after closed manipulation, and comminuted
intra-articular fractures when adequate closed reduction is
able to be obtained but likely not maintained without
additional support.
Percutaneous pin fixation is an excellent technique (Fig
2), provided that the distal aspect of the radius is not severely
comminuted or osteoporotic, because the trabecular bone of
the metaphysis provides little inherent stability. A variety of
different techniques have been described in the literature.
Kirschner wires can be placed through the radial styloid
(trans-styloid), within the fracture site (intrafocal), into distal
fragments to aid in reduction, and across the distal radioulnar
joint for treatment of gross instability of the distal radioulnar
joint. Another method of percutaneous pin fixation is the
intrafocal pin technique of Kapandji, which is best reserved
for noncomminuted extraarticular fractures In this technique,
the Kirschner wires are introduced into the fracture site itself,
rather than through the distal fracture fragment. With severe
comminution in both the articular and the metaphyseal
region, a combination of percutaneous pins, internal fixation,
and external fixation is frequently required in order to
maintain reduction. (Fig 3)
Pins that are used for less than 6 weeks are left protruding
from the skin. Pins that are to be left in place longer than 6
5
weeks are buried .
Fig. 3
Fig. 4
Fig. 2
29-39
External Fixation
An external fixation device is often an important part of the
treatment of fractures of the distal radius. In many instances of
severe comminution of the metaphysis, the surgeon can
reconstruct the articular surface but cannot stabilize it to the
shaft of the radius. An external fixation device can allow

Kotwal et al.
38
alignment of the articular surface with the
shaft without reliance on support from the metaphysis.
External fixation devices are an excellent means of
overcoming the displacing forces of the forearm muscles that
can pull comminuted distal radial fractures into a collapsed,
shortened position.
Indications for external fixation include:
1. Longitudinal traction for extra-articular fractures
with an unstable metaphysis
2. An indirect reduction assistant during ORIF
3. An adjunct to percutaneous pinning
4. Spanning open fractures
A large variety of devices are available for external fixation of
fractures of the distal aspect of the radius. All involve
distraction across the wrist joint with placement of pins in the
radius and the metacarpals (fig 4). Excessive flexion or ulnar
deviation must be avoided, as either position increases the risk
of compression of the median nerve, reflex sympathetic
dystrophy, and extrinsic tightness, causing stiffness of the
finger. The ability to position and adjust the amount of palmar
translation across the fracture site with use of more
sophisticated external fixation devices provides improved
reduction and allows the wrist to be placed in the optimal
physiologic position of extension. Over distraction is
assessed by observing the distance between the capitate and
the lunate. A gap that is >2 mm indicates that too much force is
being used. Also, the fingers should be able to be passively
flexed with ease.
Kirschner-wire augmentation (Fig 3) can substantially
improve stability of an unstable extra-articular fracture of the
distal radius regardless of the type of external fixator used.
The addition of a dorsal pin in combination with an external
fixation device can easily correct the dorsal tilt found in many
fractures of the distal radius.
Operative Approaches to Distal Radius
Three approaches, two volar and one dorsal, are used most
15
frequently for exposure and fixation of the distal radius . The
approach chosen is based on the configuration of the fracture
and the planned placement of fixation.
40-51
Plate fixation
Internal fixation devices and techniques have improved
substantially. The need to fix both large extra-articular
fragments as well as smaller intra-articular fragments is
necessary in many complex fractures. Buttress plates (Fig 5)
have been shown to provide excellent stability for an unstable
fracture with either dorsal or volar metaphyseal
comminution. Some designs also provide smaller screws or
pins in the transverse distal segment of the plate, which
facilitates fixation of smaller articular fragments. Dorsal
buttress plating was introduced in an attempt to achieve better
control of articular reduction and improve stability. Because
most distal radius fractures tend to collapse dorsally, this
technique relies on the buttress effect. A disadvantage is that
dorsal plate application alters the normal tendon-to-bone
relationship of the extensors and subjects the dorsal tendons
to hardware friction.
Fig 5
Soft-tissue complications associated with a dorsal plate,
including extensor tendon irritation and late rupture, have
been attributed to the prominence of the plate and/or screw
heads. Newer designs have minimized these complications
because they incorporate precontouring by the manufacturer,
allow ease of further contouring by the surgeon, and use a
plate and screw heads with a low profile.
There is a correlation between the functional outcome
following a distal radial fracture and the restoration of both
the radiocarpal and the radioulnar relationships. However,
they are frequently difficult to restore in osteopenic and

Pb Journal of Orthopaedics Vol-X, No. 1, 2008
Fractures of the Distal Radius: Current Concepts
39
unstable fractures. The development of angular stable
fixation techniques with use of implants designed specifically
for the anatomy of the distal end of the radius improves our
ability to manage these problems. In these implants, stability
is not achieved by the creation of friction between the plate
and bone as in traditional screw-plate fixation, but rather
mechanical bridging of the bone and load-bearing are allowed
through the locked screw-plate construct (Fig 6). Lockinghead
screws do not rely on the bone thread for purchase; and
screws that lock into the plate prevent loosening within the
implant, so early failure of fixation with an angular stable
implant will occur only if the entire screw-plate construct
pulls out from the bone or there is material failure of the
implant.
stopped, but before the hematoma has consolidated. The
greatest value of arthroscopy may be an improved ability to
assess how successful articular restoration has been because it
is becoming increasingly clear that plain radiographs and
fluoroscopy are not always reliable in assessing small
displacements.
Bone graft
During the healing process, collapse of the distal fragments
into the cancellous defects in the metaphyseal and
subchondral regions can lead to secondary displacement and
55
loss of reduction .
Bone graft or bone substitutes are frequently used to fill
the metaphyseal void for added support of the articular
surface during healing. Autogenous bone graft is the gold
55
standard , however morbidity associated with harvesting of
this, has led to use of allograft and various bone substitutes.
This area of molecular orthopaedics is burgeoning, and
further objective, comparative and longer term studies are
required to assist in decision making and finding the optimum
bone substitute.
Fig. 6
Biomechanical studies have emphasized the need for
placement of the distal most screws or pegs just beneath the
subchondral bone of the articular surface to achieve the
maximum benefit of volar fixed-angle plate fixation.
52-54
Arthroscopic assisted reduction
Advances in arthroscopic technique have added
significantly to our armamentarium for the treatment of distal
radius fracture. Arthroscopic visualization and reduction
techniques are particularly helpful, for example, in restoring
an incongruous joint surface in the setting of a single, large,
depressed, radial, styloid fragment. Arthroscopically assisted
reduction and fixation require traction and adequate
visualization. It is advisable; therefore, to use this technique
between 4 and 7 days after fracture when bleeding has
5
High energy injuries
High energy trauma to distal radius results in usually a
comminuted fracture pattern and may require a combined
dorsal and volar approach, needing expertise care. These
injuries may result in open fractures and are dealt with
aggressive debridement and stabilization with internal or
external fixation. Ideally soft tissue coverage should be
restored within 1 week of injury and bone grafting is done
when soft tissues have healed.
In case of closed fractures associated with significant
swelling, it is prudent to wait for the swelling to subside and to
delay the procedure.
5, 8-9
Associated Injuries
Injuries to distal radioulnar joint (DRUJ) and fracture of
ulnar styloid are frequently associated with distal radius
fractures. Evaluating the stability of DRUJ is essential in the
treatment of wrist fractures. If the DRUJ is stable, the ulnar
head is reduced and is stabilized with K –wires. Associated
fractures of ulna also need stabilization. Small avulsion
fractures of the ulnar styloid process do not necessitate
additional treatment. However, fractures near the base of the
ulnar styloid process include the entire insertion of the ulnar
border of the triangular fibrocartilage complex and need
fixation. Options for fixation include K wires, tension band

Kotwal et al.
40
wiring, mini-screws or Herbert screw fixation.
Intercarpal injuries have also been identified most frequently
in association with fractures involving the lunate facet of the
distal articular surface of the radius. High energy injuries,
especially those involving shearing or avulsion of the radial
styloid, is frequently associated with Scapho-lunate injuries
and should be treated with pin fixation at least or repaired as
part of any open procedure.
Postoperative care and rehabilitation
The goal of rehabilitation therapy should be to start patients
on a program of active and passive motion of the digits, elbow,
shoulder, and rotation of the forearm within twenty-four
hours following surgery. Early motion decreases tendon
adhesions and reduces soft-tissue swelling. Splints and casts
must allow full range of motion of the metacarpophalangeal
joints by not extending beyond the distal palmar crease. If
plate fixation is able to provide stable fixation, treatment
involves a short arm cast or splint, and active range-of motion
exercises of the wrist are begun four to six weeks
postoperatively.
5, 8-9
Complications
Distal radial fractures are often associated with poor results
and high complication rates. High-energy fractures,
especially those involving an intra-articular component, are
especially susceptible to poor outcomes. Complications of
distal radial fractures include compressive neuropathy,
malunion, tendon rupture, radioulnar and radiocarpal
arthrosis, and finger stiffness. Mild forms of reflex
sympathetic dystrophy are quite common with distal radial
fractures. Tendon ruptures due to irritation over a plate occur,
but they are infrequent. The extensor pollicis longus and
49
common extensor tendons are most commonly affected . A
prominent dorsal plate and screws cause irritation and
synovitis, which leads to late rupture. Other complications
include flexor or extensor tendon entrapment in the fracture or
the distal radioulnar joint and the development of palmar
fascial nodules.
Summary
Intra-articular fractures of the distal aspect of the radius are a
heterogeneous group of injuries with different fracture
patterns. Treatment of displaced fractures of the distal end of
the radius has changed over the course of time. Over the past
twenty years, more sophisticated internal and external
fixation techniques and devices for the treatment of displaced
fractures of the distal end of the radius have been developed.
The use of percutaneous pin fixation; external fixation
devices that permit distraction and palmar translation; lowprofile
internal fixation plates and implants; arthroscopically
assisted reduction; and bone-grafting techniques, including
bone-graft substitutes, all have contributed to improved
fracture stability and outcome.
We recommend conservative management for
nonarticular, non-displaced fractures. Percutaneous pinning
or ORIF with plate fixation is appropriate for irreducible,
displaced extraarticular fractures. ORIF with buttress plate
fixation remains treatment of choice for partial articular
fractures like Barton's fracture. ORIF with locking plate
remains treatment of choice for comminuted articular distal
end radius fractures. The accuracy of the reconstruction of the
articular surface, with the goal of establishing congruency to
within 1.0 millimeter, is also important in order to minimize
the risk of late osteoarthritis. Arthroscopic facilities, if
available should be utilized for assessing articular surface
reduction. External fixation remains a useful adjunct for the
management of open fractures and also for indirect reduction
techniques.
Notwithstanding the value of new devices, however,
appropriate judgment remains critical, especially in choosing
between operative and nonoperative treatment. Indeed, it is
worthwhile acknowledging again the relative importance of
restoring radial length and articular congruity, and yet the
observation that functional outcome may not correlate with
radiographic appearance.
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