Distal-Third Forearm Fractures Treatment & Management
- Author: Arvind D Nana, MD; Chief Editor: Harris Gellman, MD more...
Closed treatment methods are indicated for stable fractures. Stability is predicated on accurate reduction and adequate bony integrity to maintain that reduction. Surgical treatment may be necessary for injuries that are identified as unstable.
Nondisplaced extra-articular and intra-articular fractures
For nondisplaced extra-articular and intra-articular fractures of the distal radium, immobilization without fracture manipulation is recommended. Experience has demonstrated that a circular cast or even a bivalved cast has the potential for complications, such as compartment syndrome and swelling of the digits. A padded sugar-tong plaster splint with 20-30° of wrist palmar flexion and neutral rotation is a safe alternative, and the elastic bandages around the sugar-tong plaster splint can be adjusted later to accommodate decreased swelling, without manipulation of the fracture.
Three-point molding is an important aspect of the sugar-tong plaster splint because this helps maintain reduction of the fracture. Appropriate molding along the dorsal distal radius, volar distal forearm, and dorsal proximal forearm helps achieve adequate 3-point molding. The authors have found that a flat surface of the splint along the volar distal forearm is key to achieving 3-point molding (see the images below).
The sugar-tong plaster splint with its U shape around the elbow prevents pronation and supination but allows some elbow motion. Elimination of pronation and supination neutralizes deforming forces (eg, brachioradialis) on the fracture fragments. Wrinkles in the splint must be avoided, especially on the volar side because such wrinkles can cause local compression of the median nerve, carpal tunnel, and volar skin. Conversion to a short arm circular cast is not always necessary or recommended; however, if it is necessary, it should be done at 2-4 weeks after sugar-tong plaster splint immobilization.
Plain radiographs should always be obtained after splinting to confirm that the fracture fragments are not displaced. Radiographs should be acquired every week for 2-3 weeks after immobilization to ensure stability of the fracture. Maintaining the wrist above the level of the heart and early finger motion facilitate rapid improvement of swelling. During the period of immobilization, finger motion and "six-pack" finger exercises, as Palmer describes, are important and should be performed at least 3 times a day as shown in the image below. These exercises emphasize finger extension, metacarpophalangeal joint flexion, proximal interphalangeal joint flexion, full finger flexion, finger abduction and adduction, and thumb motion.
After immobilization for a total of 4-6 weeks, the recovery of pronation and supination and wrist flexion and extension should be emphasized. Occupational therapy may be necessary during or after immobilization if the patient has difficulty with finger motion or wrist motion, respectively. Strenuous activities with the affected wrist should be restricted for the first 3 months after injury.
Displaced extra-articular and intra-articular fractures
All displaced distal radius fractures should initially be treated with CR and fracture manipulation and immobilization in a sugar-tong plaster splint. Even if adequate reduction is not achieved, the initial CR limits injury to the nerves, tendons, and soft tissues as a result of the displaced bone fragments. Manipulation of the fracture can be achieved in the emergency room or outpatient clinic by using a hematoma block and/or sedation or by using a Bier block. Local hematoma block without sedation is believed to be a safe option in the outpatient setting and can be performed as long as 7-10 days after injury.
Longitudinal traction with finger traps is helpful during CR, and if used, the traction should be maintained for several minutes before fracture manipulation to take full advantage of ligamentotaxis and tissue creep. Plain radiographs and, ideally, fluoroscopic images can be used to assess the fracture reduction with traction. If the reduction is inadequate, the fracture can be easily manipulated again.
Articular congruity of the sigmoid notch of the distal radius is just as essential as that of the radiocarpal joint. If the fracture line involves the sigmoid notch, motion arthroplasty of the sigmoid notch can be achieved by pronating and supinating the forearm during the reduction maneuvers. Adequate reduction of the sigmoid notch must also be evaluated on traction and postreduction views.
If adequate reduction is achieved with fracture manipulation, a sugar-tong plaster splint should be applied, with the longitudinal traction in place. As the splint is setting up, the longitudinal traction can be released, and the dorsal and palmar 3-point molding of the sugar-tong plaster splint can carefully be completed with light manual traction. The wrist should be placed in 20° volar flexion, neutral rotation, and 15° ulnar deviation to take advantage of ligamentotaxis and 3-point molding. Once the splint is hard, manual traction is released and plain radiographs ordered. Continue the immobilization if the radiographs demonstrate maintained reduction, but operative treatment should be considered if the fracture becomes displaced in the splint. Scheduled follow-up visits with plain radiography are essential in the treatment of distal radius fractures.
If adequate reduction criteria are not achieved, surgical intervention is necessary, as outlined in the Table. In the interim before surgery, sugar-tong plaster splinting can be used to immobilize the fracture and limit damage to surrounding structures. High-energy injuries are often associated with extensive swelling, and operative intervention should be performed after swelling has decreased, usually several days after injury.
Unlike nondisplaced fractures of the distal radius, fracture displacement implies more injury to the soft-tissue envelope; therefore, splint immobilization should be continued for a minimum of 6 weeks or longer.[23, 47] Conversion to a short arm cast can be considered after 4-6 weeks of immobilization. Wrist immobilization, if applied properly, can be maintained for 6-8 weeks without additional adverse effects on the long-term functional outcome. After cessation of immobilization, the same protocol as for nondisplaced fractures must be followed.
Surgical treatment is indicated for unstable distal radius fractures. An unstable injury is defined as a fracture that does not reduce adequately with closed fracture manipulation or that loses reduction below acceptable reduction parameters despite appropriate immobilization techniques.[48, 49]
Dorsally displaced extra-articular fractures
CR and percutaneous pinning is a simple and effective treatment for dorsally displaced extra-articular fractures with large metaphyseal fragments. Cross pinning with 0.062-inch diameter smooth pins in the radial styloid (2 pins) and dorsal ulnar aspect of the distal radius (1 pin) has been shown to be a rigid construct in both torsion and cantilever bending.
The radial styloid is anterior so the radial styloid pins are to be directed in a dorsal proximal ulnar direction. To avoid injury to the extensor tendons, the percutaneous pin should be inserted between the extensor tendons of the first and second, third and fourth, and/or fourth and fifth compartments, as shown in the image below.
Intrafocal (Kapandji) pins are another consideration, especially in the physiologically younger patient, but they should not be used initially in the presence of significant comminution or advanced osteopenia.[27, 52, 51] This technique is especially useful for reducing and holding fractures that redisplace after several weeks of immobilization.
Extensive comminution at the fracture site can occur in physiologically young patients involved in high-energy injuries and in osteoporotic patients with low-energy trauma. When these fractures are reduced, the metaphyseal bone has resultant voids, which require filling with iliac crest bone grafts, allografts, or bone-graft substitutes.
McBirnie et al found a 22% malunion rate in unstable distal radius fractures treated with bone grafting and fixation with a single Kirschner wire. This rate suggests that additional support, as with an external fixator or plate, is necessary with this type of treatment. The authors do not use dorsal plates for acute fractures, because some plates can irritate the extensor tendons, and they frequently have to be removed. Newer low-profile plates and screws are now available. New external fixators are easy to apply in neutral tension and can be used for fine-tuning difficult reductions. In association with dorsal bone grafts, external fixators maintain neutral tension in the dorsal aspect and can be removed early (4 wk) in some fractures.
Bone-void filler provides mechanical support and applies an osteoconductive material to the bone defect.[54, 55, 18, 29] The use of filler ultimately leads to more rapid fracture healing and a decreased incidence of the loss of reduction.
Volarly displaced extra-articular fractures
Like its dorsal counterpart, a volar displaced fracture with noncomminuted metaphyseal fragments responds well to CR and percutaneous pinning, which effectively restores the volar buttress in the presence of large volar metaphyseal fragments. The use of dorsal intrafocal pins for stabilization is controversial because they may aggravate the volar displacement and not restore anatomic alignment. Proper palmar tilt is readily achieved with CR; however, excessive palmar tilt is still possible if volar metaphyseal fragmentation is not properly evaluated on initial radiographs.
With small, comminuted, volar metaphyseal fragments, compression of cancellous bone is expected, with resultant loss of the essential volar buttress. Volar plating stabilizes the fracture, and a bone-void filler may be added. Rigid fixation with a volar plate also permits early ROM out of the plaster splint.
Unlike small-fragment dorsal comminution, small-fragment volar metaphyseal comminution cannot be treated with ligamentotaxis because of the radiocarpal ligamentous anatomy. The volar ligaments are shorter, thicker, and stronger than the longer, thinner, and weaker dorsal ligaments. The stout volar ligaments tighten sooner with longitudinal distraction, resulting in dorsal tilt of the distal fragment.[39, 56, 57, 58] The volar capsule should not be opened because of these strong volar ligaments, which are important for radiocarpal stability. These observations further support the authors' use of a volar plate to reconstruct the volar buttress in the presence of significant volar metaphyseal fragmentation.
Intra-articular fractures involving dorsal and/or volar metaphyseal fragments are a combination of intra-articular and extra-articular displaced injuries. As such, their treatment plans are additive. Ideally, all intra-articular fragments should be anatomically reduced to retard the development of OA. CR and splint immobilization techniques are similar to those used for extra-articular fractures.
Dorsally displaced lunate facet die-punch fractures
Dorsally displaced lunate facet die-punch fractures need to be anatomically reduced (with either an open or closed technique) to realign the radiolunate joint and the sigmoid notch and to restore the integrity of the medial complex. The dorsal ulnar fragment can be treated with closed reduction and stabilized with a single pin. However, a limited dorsal open reduction between the fourth and fifth extensor compartments may be necessary.
If the dorsal metaphyseal fragments are small (comminuted), dorsal bone grafts (or substitutes) and external fixation are recommended, as described for extra-articular comminuted fractures. In either case, the intact volar cortex serves as a buttress against which stability of the dorsal fragment is maintained.
Volarly displaced lunate facet die-punch fractures
The volar fragment of the coronal split has a tendency to rotate dorsally when tension is applied to the volar capsule, and such displacement requires a volar open reduction. If this occurs, the volar medial fragment is buttressed with a small plate (see the image below). Volar plating does not have the same complications as the dorsal plate and does not necessitate routine early hardware removal.
Dorsal and volar metaphyseal fragments
When displacement (instability) of dorsal and volar metaphyseal fragments is present, dual approaches are necessary. As always, a stable volar buttress is critical for providing a fulcrum against which the dorsal fragments are reduced. Volar plating provides this stability and prevents excessive volar displacement secondary to manipulation of dorsal fragments and/or placement of bone grafts. When dual incisions are necessary, an attempt should be made to close the volar incision before the dorsal incision is made to minimize tissue swelling and to limit skin tension with wound closure.
Radial styloid fractures
The isolated radial styloid fracture (ie, chauffeur's fracture) is uncommon. When present, this fracture should be critically evaluated for associated injuries, such as a scaphoid facet die-punch fracture and, more importantly, a carpal ligament injury.
This fracture responds well to CR and can successfully be pinned percutaneously. However, if small metaphyseal fragments are present or if CR is not successful, open reduction internal fixation through either a direct dorsal approach or a standard volar (Henry) approach must be considered. The latter is chosen when the styloid fragment is displaced volarly or when it has a large volar extension.
Most often, the styloid fragment is part of a 4-part displacement pattern, as Melone described. In this instance, the treatment of all components is additive. The reduction and stabilization of the radial styloid, dorsal lunate facet die-punch, and volar lunate facet die-punch fractures are assessed and treated as described above, either individually or in combination.
Central depression fractures
Central depression of lunate or scaphoid facets should be evaluated with CT scanning or plain tomography to fully assess the magnitude of articular step-off. Impacted fractures more than 1-2 mm should be treated with reduction via a limited dorsal approach, with bone grafting for mechanical support, and with percutaneous pinning for stability.[29, 59] The reduction can be confirmed by means of fluoroscopy or, more precisely, by direct visualization (capsulotomy) or arthroscopy. Arthroscopically assisted reductions have the advantage of minimizing capsular scarring; however, no available data show that arthroscopy improves outcomes.
Distal radius fractures can directly or indirectly cause contusion, laceration, and/or entrapment of skin, tendons, nerves, fascia, muscle compartments, and vessels by bone fragments.[60, 61] The potential for early soft-tissue complications increases with any delay in initial treatment; therefore, early initial reduction of the fracture can minimize the effects of these associated injuries.
Iatrogenic injury must also be avoided regardless of whether treatment is conservative or surgical. Cast treatment can lead to skin pressure necrosis and median nerve compression. Joint contractures are associated with the Cotton-Loder position (ie, excess palmar flexion with ulnar deviation). Circumferential casts or dressings cannot allow for expected swelling, and compartment syndrome can subsequently occur. Persistent finger edema can also result in stiffness of the digits. Casts that block finger motion are unnecessary and potentially harmful.
Surgical management of distal radius fractures can also result in complications. Percutaneous placement of pins is technically simple but can easily injure extensor tendons and nerves. Excessive traction by external fixation can lead to joint stiffness and injury of carpal ligaments. Careful handling of soft tissues in all surgical approaches is essential to prevent postoperative skin damage and infection.
Caution should be used when bone grafts are used in intra-articular fractures to avoid intra-articular extravasation. Rupture of the extensor pollicis longus (EPL) can occur with surgical or nonsurgical treatment. Careful reduction of dorsal fragments helps to avoid this complication. In dorsal approaches to the wrist, releasing the EPL tendon from its compartment can also help to avoid tendon constriction and injury.
Early reflex sympathetic dystrophy (RSD) should always be suspected in the presence of inappropriate postoperative pain, swelling, and stiffness. RSD may be caused by tight dressings, unresolved nerve injury (eg, carpal tunnel syndrome), or inherent patient susceptibility to this complication. In any event, early recognition and treatment is effective in most cases. Removal of the instigating factors, active ROM of thumb and fingers, sensory stimulation, activities of daily living of the hand, and psychotropic medication all have beneficial effects.
The list of long-term complications associated with distal radius fractures is extensive and not within the scope of this article. This section provides a general overview of the common problems. Pain and extremity function should guide the treatment plan; radiographic findings guide the surgical approach.
Extra-articular malunion is often multidirectional and can result in malalignment of the DRUJ and the carpal bones. Typically, extra-articular malunions are shortened and tilted dorsally and treated with distal radial osteotomy, corticocancellous bone grafting, and dorsal-plate fixation. On correction of the distal radius alignment, the radial length and reduction of the DRUJ must be critically assessed.
Further considerations include ulnar shortening, distal ulnar ablation (Darrach), partial distal ulnar resection with or without interposition arthroplasty, or distal radioulnar fusion with ulnar pseudarthrosis (Sauve-Kapandji). Many of these DRUJ procedures can be performed without correction of the distal radius malunion.[17, 21, 22, 63]
Although many patients report excellent results after reconstruction of distal radius malunions (particularly DRUJ malalignment), data from good long-term outcome studies are unavailable. An intra-articular step-off more than 2 mm can lead to degenerative arthritis, but these radiographic findings have not been correlated with long-term patient outcomes.
Following treatment of distal radius fractures, functional impairment is possible for as long as 2 years. For this reason, the authors continue aggressive therapy, including active and active-assisted ROM, progressive-resistance exercises, and work rehabilitation for as long as improvement is noted objectively. Only then is it appropriate to assess the need for reconstructive surgery.
Outcome and Prognosis
Fractures of the distal radius are not simple injuries and, thus, require careful evaluation of the radiocarpal joint, the DRUJ, and carpal bones. However, educated decision making based on objective data and patient profile can lead to optimal outcomes of these challenging fractures.
The prognosis is dependent on the functional expectations of the patient, and as such, anatomic restoration of the distal radius and early radiocarpal joint mobilization are important for patients with high functional demands.
The magnitude and direction of displacement and the type of fragmentation at the fracture site are important factors determining the treatment plan; such treatment recommendations based on these critical parameters is presented in the Table. Important aspects of this classification system can be summarized as follows:
An intact volar buttress is the key to a stable reduction. When disrupted, this buttress must be restored.
All intra-articular fractures have 1 or more components of the Melone 4-part pattern, and each component must be addressed and stabilized.
Dorsal bone grafting is an important adjunct in promoting stability and healing when dorsal metaphyseal comminution is present.
External fixation should be used in conjunction with dorsal bone grafting when dorsal comminution is present. The external fixator should be used as a neutralization device and can be removed early (4 wk) when used in this fashion.
Every patient is unique, and the ultimate treatment plan should be based on individual needs and expectations.
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|Stable (nondisplaced or reduced)||CR, splinting|
Large dorsal metaphyseal fragments
Small dorsal metaphyseal fragments (comminuted)
Large volar metaphyseal fragments
Small volar metaphyseal fragments (comminuted)
|CR, PP, splinting
Limited dorsal OR, BG, external fixation
CR, PP, splinting
Volar plating with or without BG
|Stable (nondisplaced or reduced)||CR, splinting|
Large dorsal metaphyseal fragments
Small dorsal metaphyseal fragments (comminuted)
Volar fragments (large and small volar metaphyseal fragments)
Dorsal and volar fragments
Large dorsal metaphyseal fragments
Small dorsal metaphyseal fragments (comminuted)
Radial styloid fracture‡
Large metaphyseal fragments
Small metaphyseal fragments (comminuted)
Central depression fracture
|CR, PP, splinting
Limited dorsal OR, BG, external fixation
Volar plating with or without BG
Volar plating, dorsal PP
Volar plating, limited dorsal OR, BG, external fixation
CR, PP, splinting
CR, PP vs OR, volar radial plating
Limited dorsal OR vs AR, BG, PP
|Source.—Adapted from Beaty.
* AR indicates arthroscopic reduction; BG, bone grafting of void (eg, iliac crest bone graft, allograft, bone graft substitute); CR, closed reduction; OR, open reduction; PP, percutaneous pinning.
† Closed reduction with manipulation should be attempted on all displaced fractures, and surgery should be considered only in cases of inadequate closed reduction or loss of reduction with splint immobilization.
‡ Can be considered separately or in combination with other intra-articular fractures.