Distal Radius Fractures Treatment & Management
- Author: David L Nelson, MD; Chief Editor: Harris Gellman, MD more...
No consensus has been reached on classification systems, indications for surgery, or a particular choice of surgery since the orthopedic community first rejected Colles' contention that all distal radius fractures (DRFs) heal well. Gartland and Werley are generally credited with starting the revolution in 1951 with their paper examining more than 1000 DRFs, and Jupiter brought the discussion into the modern era with his 1986 paper in the Journal of Bone and Joint Surgery that emphasized the importance of reduction.
Despite the large number of papers published each year on DRFs, no consensus has been reached on treatment, and there is nothing in the literature to suggest that a consensus might be developing. Indeed, with one approach advocating immediate motion using a fixed-angle volar plate and another advocating immobilization for 3 months using an internal joint-spanning plate, treatment options seem to be diverging rather than converging.
One area of agreement is that DRFs in active adults should be reduced anatomically. Unfortunately, however, no consensus has yet been reached on precisely what "anatomically" means in this context. That is, is a 0.5-mm displacement of an intra-articular fragment "anatomic"? What if it is extra-articular? Is the same definition of "anatomic" appropriate both for young, active patients and for older, inactive patients?
Even with classification (see Presentation, Classification), no consensus has been reached. The International Federation of Societies for Surgery of the Hand formed a working group of the most distinguished minds in DRF management to investigate for the existence of a consensus on the best classification system or, if one did not exist, to develop one. This working group concluded that no available system was universally useful or accepted and that the group could not develop a system that would be.
There is, however, a consensus that the goal of treatment is to restore the patient to the prior level of functioning. This is the starting point for all discussion.
Indications for reduction or operative treatment
Most authors advocate an anatomic reduction. This admonition, however, has two problems. First, not all patients need an anatomic reduction to be able to resume their normal activities. Second, the concept of "anatomic" reduction is not defined, as noted above. No authorities advocate operative reduction if the stepoff is 0.5 mm; however, a stepoff of 0.5 mm is obviously not anatomic. On the other hand, a 20° dorsal tilt is not anatomic, yet inactive elderly adults can easily return to their previous level of functioning with this alignment.
The indications for reduction or operative treatment are not based solely on age but must be tailored to the individual patient. It is also important, however, not to err in the opposite direction—that is, by considering that any patient who is "old" does not require an anatomic reduction (one paper defined "old" as 50 years old!). Balanced judgment is required.
Most authors would recommend anatomic reduction in a patient who is active in recreation (remembering that golf and tennis are common activities for persons older than 70 years) or engages in forceful activities at work. Conversely, if the patient is sedentary, a lesser reduction may allow return to full activities. Usually, three parameters are relevant:
Intra-articular stepoff - Most authors would accept less than 1 mm of intra-articular stepoff but not more than 2 mm
Dorsal tilt - Most authors would accept neutral dorsal tilt but not more than 10° (the range is quite large in the literature, with some authors not accepting more than neutral)
Radial length - Most authors would accept 2 mm of radial shortening but not more than 5 mm
Radial tilt is generally considered a lesser parameter.
Defining anatomic reduction in terms of intra-articular stepoff is challenging. The main challenge lies in making a reliable determination of the relevant parameters—that is, how to distinguish between less than 1 mm and greater than 1 mm. (See Indications for Reduction in Distal Radial Fractures.) The difficulty is that opinions are based on studies using routine plain radiographs, which cannot accurately measure stepoffs with an accuracy of 1 mm.
The threshold of 1 mm for intra-articular displacement is commonly cited, referencing a 1986 landmark paper by Knirk and Jupiter. However, Jupiter has repeatedly stated that this threshold is not the benchmark that subsequent authors have used, that the 1986 study had methodologic flaws, and that ligamentous injuries may account for functional limitations better than intra-articular stepoff does. Surgeons must review the literature with this in mind, because it changes the reliability of the conclusions reached by many authors after 1986.
Fewer comparative studies (either basic science or clinical) have been published on dorsal tilt, but this has not kept authors from making pronouncements. The range of anatomic alignment for dorsal tilt has reportedly been from 0° to 10°, with no proviso for less active patients. Given that a neutral (0°) alignment represents an 11° loss of volar angulation, even the most conservative figure is not truly anatomic.
Commonly, some older, inactive patients are able to achieve full resumption of their activities with dorsal tilts of 45° or more. Although orthopedic surgeons may find the radiographs of these patients disturbing and the clinical deformity not much better, some patients are quite satisfied and able to function in all of their ADLs. This calls into question any rigid threshold of dorsal tilt, whether it be 0° or 10°. Most authors recommend no more than 0-10° of dorsal tilt in healthy, active individuals.
The basic science of radial length is clear. Shortening radial length by 2 mm doubles the load through the triangular fibrocartilage (TFC) and the ulna. The clinical relevance of this fact in the context of DRFs is unclear. Additionally, altering the radius length relative to the ulna affects the function and forces associated with the distal radioulnar joint (DRUJ). On the basis of less well-defined clinical grounds, most authors would not accept more than 2-5 mm of shortening.
For more information, see Indications for Reduction in Distal Radial Fractures.
Stability of reduction
Another issue that has not been resolved is the stability of the reduction if it is performed in a closed procedure and without operative support to the fracture fragments. Some authors believe that a 30° dorsal tilt or any radial shortening will not be stable and will subside. If function requires that reduction be achieved, surgery is needed to maintain it.
Agreement has been reached that weekly radiographic assessment is required for approximately 3 weeks. Fractures do not commonly subside after 3 weeks, but this is not a certainty. Care must be taken to compare the current radiograph with the postreduction radiograph because subsidence is gradual and can be difficult to detect.
Choice of treatment approach
Management of DRFs has always been an area of intense research and innovation. It has changed more rapidly in the past decade than in any previous two decades. Whereas percutaneous pinning and external fixation remain the mainstays of treatment throughout much of the world, with strong and somewhat idiosyncratic national trends attributable to the prominence of individual surgeons in those countries, volar fixed-angle plating has become popular and has dramatically shifted the landscape in several ways.[8, 9]
For many surgeons, the volar approach, using fixed-angle devices, is the main treatment option for dorsally unstable DRFs. Orbay has popularized this treatment and broadened its applicability to highly comminuted intra-articular fractures with the extended flexor carpi radialis (FCR) approach, pronating the radial shaft out of the way and looking directly at the undersurface of the articular bone.
The low rates of complications and postoperative pain, the quality of the results, and the rapid return to activities have, for some surgeons, shifted the balance of risks to benefits in such a manner that they are offering patients the option of surgery versus a cast for stable undisplaced or stable reducible fractures.[10, 11] (See Radius Fracture with Immediate Return to Work.)
The complication rate for volar fixed-angle plates has not yet been clearly defined. Most cases of tendon injury or rupture seem to be due to failure to follow proper technique. One aspect of technique is to avoid any past-pointing of distal screws and, preferably, to place their tips 2-4 mm short of the dorsal cortex. A second important technique is to use a plate that does not extend distally as far as the volar wrist capsule and to completely and securely cover it with the pronator quadratus (PQ).
Arthroscopy continues to be a controversial adjunct to the management of intra-articular fractures. Whereas the rate of unrecognized scapholunate, lunotriquetral, and triangular fibrocartilage tears in DRF has been shown to be greater than 60%, the role of arthroscopy continues to be controversial because of a lack of any outcome studies that have demonstrated improved results.
In the treatment of DRFs, the goal is to return the patient to his or her prior level of functioning. The physician's role is to discuss the options with the patient, and the patient's role is to choose the option that best serves his or her needs and wishes. This treatment paradigm can be illustrated by a case discussion of an approach to the surgical treatment of stable fractures that are in acceptable alignment (see Radius Fracture with Immediate Return to Work).
Many DRFs can be treated nonoperatively. Those that are undisplaced or minimally displaced (the definition of minimally displaced is controversial and varies with age and activity level) can be treated in a cast for 6 weeks. In most instances, unless the distal ulna is fractured and unstable (type I and II ulna fractures are usually stable), it can be treated in a short arm cast. Long arm casts are not required if the ulna is stable; additionally, these casts significantly disable the patient during the treatment of the fracture.
Some fractures in elderly persons that are compressed dorsally can be minimally painful and can appear to be clinically stable. These fractures may be treated with a splint only. This variant is somewhat rare.
Elderly, low-activity patients can have very high function and return to prior activities even with a significantly displaced fracture. A 45° dorsal tilt can be highly functional in a patient who does not drive and is not active outside the home. Clinically, such patients have an unsightly wrist (with a prominent ulnar head) that has limited supination and flexion, but they do not have symptoms with activities of daily living (ADLs). Success in these cases strongly depends on the patient, not the surgeon, making the treatment choice.
A systematic review concluded that, in patients with DRFs who are aged 60 years and older, cast immobilization provided functional outcomes similar to those achieved with surgical treatments (volar locking plate system, nonbridging external fixation, bridging external fixation, or percutaneous Kirschner wire [K-wire] fixation). Cast immobilization had the worst radiographic outcome yet the lowest complication rate. Additional studies are needed to evaluate the recovery rate, cost and outcomes of these treatment methods.
In 2009, the American Academy of Orthopaedic Surgeons (AAOS) issued a clinical guideline on the treatment of DRFs. Many of the recommendations in the guideline lacked strong supporting evidence and were considered inconclusive. However, the following recommendations were supported by moderately strong evidence:
Rigid immobilization is suggested in preference to removable splints in nonoperative treatment for the management of displaced DRFs
For all patients with DRFs, a postreduction true lateral radiograph of the carpus is suggested for assessment of DRUJ alignment
Operative fixation is suggested in preference to cast fixation for fractures with postreduction radial shortening greater than 3 mm, dorsal tilt greater than 10º, or intra-articular displacement or stepoff greater than 2 mm
Patients probably do not need to begin early wrist motion routinely after stable fracture fixation
Adjuvant treatment of DRFs with vitamin C is suggested for the prevention of disproportionate pain
On the basis of the available evidence, the AAOS was unable to make a recommendation for or against casting as definitive treatment after initial adequate reduction or to recommend any specific surgical method over another.
Traditionally, surgical treatment has been reserved for displaced, irreducible DRFs or reducible but unstable DRFs. One approach that is becoming more popular is to provide surgical treatment to patients who cannot or do not want to accept the constraints of cast treatment because of ADL, work, or recreational concerns.
No consensus has been reached as to which surgical treatment is best. Several options are available, each with its own variations.
Closed reduction and percutaneous pinning
Closed reduction and percutaneous pinning has been popular for many years and continues to be one of the most popular techniques internationally. The pinning can be of several varieties, including Clancey pinning (ie, 0.062-in. wires into the radial styloid and the dorsal ulnar corner of the radius, crossing the fracture site; see the images below) and Kapandji pinning (ie, wires or arum pins placed into the fracture site dorsally and used as levers to reduce the fracture and then to stabilize it).
External fixation (see the image below) became the most popular treatment throughout much of the world in the decades after the development of a radius-specific fixator by Anderson in 1944. The proper application technique, however, was not defined until 1990 by Seitz. Small open incisions are used to avoid injuring the sensory branches of the radial nerve and to ensure central placement in the second metacarpal and the radial shaft. This technique continues to be one of the most popular approaches internationally.[18, 17]
Many variations of external fixation have been developed. One variation of the fixator allowed early motion with the fixator still in place. The concept was originated by Clyburn and popularized internationally by Pennig. The axis of motion of the fixator was placed over the center of motion of the wrist, thought to reside in the center of the head of the capitate.
This approach has largely been abandoned because of theoretical criticisms and clinical experience. The theoretical criticisms are related to the location of the rotation—that is, whether it is an instant center or a constant center and whether it is possible to place the center of motion of the fixator reliably over the center of motion of the wrist. An additional practical consideration is the impossibility of having a center of motion of the fixator not coaxial with the center of the wrist.
Clinical studies also noted a decrease in final range of motion and an increase in complications related to the device; thus, early motion in external fixation has largely been abandoned. Nevertheless, some researchers are still investigating this technique, and it is still used clinically in some regions of the world.
In a study of patients with DRFs that compared complication rates after external fixation and after volar plating, the volar plate group experienced more tendon and median nerve complications; however, the external fixation group had a significantly higher overall complication rate. Whereas there were no significant differences between the groups in the scapholunate angle or palmar tilt measurements, the volar plate group had significantly better arc of motion in pronation-supination and flexion-extension and better grip strength.
The author is a proponent of external fixators; however, it should be noted that at this time, most surgeons would place a volar plate rather than an external fixator when feasible. The rate of complications after volar plating (tendon irritation, tendon rupture, loss of fixation, inadequate fixation, or plate removal) has dramatically decreased.
Some studies have shown that open reduction and internal fixation (ORIF) resulted in better grip strength and range of motion than closed reduction and bridging external fixation in the treatment of nonreducible DRFs. The results from one study noted that these benefits diminished with time; after a mean of 5 years, both groups had approached normal values.
Dorsal plating (see the images below) had its greatest popularity in the 1990s, with the development of plates specifically for the distal radius. Because of tendon irritation problems, this technique has lost most of its appeal for most fractures.
Fragment-specific fixation was originated by Fernandez, who called it the limited open approach, and was developed and popularized by Medoff, who coined the term fragment-specific. Fragment-specific fixation uses very small, low-profile plates that are specifically designed for the radial column, the central column, or the ulnar column of the radius (see the images below). This approach lends itself to many types of fractures, but it is difficult to learn, and often the plates must be removed.
Nonspanning external fixation
Nonspanning external fixation (see the image below) was popularized by McQueen and capitalized on the strength of the subchondral bone and the volar cortex. Although the proponents of this procedure touted the possibility of early motion, others found that range of motion (ROM) was poor.
Volar plating (see the images below), especially for dorsally unstable fractures, was independently developed by Orbay, Jennings, and Drobetz. It was Orbay, however, who successfully developed a practical device, promoted it internationally, and was the first to publish information on it[10, 11] ; thus, he is properly considered the grandfather of the technique. Volar plating is gaining in popularity, but its complications, particularly the incidence of tendon rupture, are now becoming recognized.[8, 17, 21, 22, 23, 24]
As noted earlier (see above), a study of external fixation versus volar plating of DRFs found that the latter led to more tendon and median nerve complications but the former to a significantly higher overall complication rate. At present, most surgeons would place a volar plate rather than an external fixator when feasible (the author is a proponent of external fixators).
The results from another study noted that extra-articular and simple intra-articular DRFs realized similar outcomes in motion, grip strength, Gartland and Werley scores, and Disabilities of the Arm, Shoulder and Hand (DASH) scores at 2 years when treated with ORIF with a volar locking plate.
In a 2014 meta-analysis of six trials that included 445 patients with unstable DRFs, Li-Hai et al determined that whereas external fixation had a lower rate of reoperation due to complications, volar locking plating yielded better functional recovery in the early postoperative period. However, the two methods resulted in comparable functional recovery at 1 year after the procedure.
Spanning internal fixation plates
Spanning internal fixation plates were originated by Becton and popularized by Ruch, and several companies make such plates. The screws are placed into the metacarpals and the midradial shaft, and the plates are removed at 3 months. This technique is relatively new, and only a few series have been published to date.
Surgical techniques internationally
Despite the many techniques and the large number of studies on DRFs, no consensus has been reached on the best surgical approach. Strong regional tendencies exist, such as volar plating in the United States, Kapandji pinning in France, and traditional external fixation in the United Kingdom and in Italy. In some regions (eg, Japan, Germany), the plates are typically removed; however, in others (eg, the United States), they are rarely removed.
After adequate anesthesia is established, prepare the skin. Many surgeons find that placing the fingers in finger-trap traction assists with reduction.
Reduce the fracture, and place a 0.062-in. K-wire into the radial styloid. Using image intensification, drive the K-wire across the fracture site and into (but not through) the opposite cortex. Pin migration can be limited by not going through the opposite cortex, but the pin must be securely in the cortex to maintain the reduction. Place the second pin into the dorsal ulnar corner of the radius. Under image intensification, drive the pin across the fracture site and into the opposite cortex. Additional pins can be placed if needed for stability.
Prepare as above, but place the pins into the fracture site dorsally. Lever the distal fragment into place with the pin, observing the reduction with image intensification, and then drive it into the volar cortex. Usually, more than one pin is used. Kapandji has developed special pins for this purpose, known as arum pins (because of their resemblance to the arum flower).
Make a skin incision directly over the FCR tendon; the incision should be approximately 10 cm long and need not cross the wrist crease.
Mobilize the FCR tendon radially, and incise the floor of the FCR tendon sheath. Distally, be aware that the course of the branch from the radial artery to the superficial palmar arch is variable and can cross the FCR tendon. Divide the septum between the FCR tendon and the flexor pollicis longus (FPL) tendon distal to the wrist crease. This avoids making a skin incision distal to the wrist crease. If, subsequently, the distal portion of the surgical field cannot be visualized adequately, release this septum further.
Release the muscular fibers of the FPL, originating from the shaft of the ulna or the septum between the radius and the first dorsal compartment. The PQ is seen, often with a tear in its fascia where the shaft has displaced and torn it at the moment of fracture.
Release the PQ 1-2 mm distal to the line marked by the distal end of the muscular fibers and the proximal end of the fibrous tissue that continues distally to become the wrist joint capsule (the so-called PQ line). Release the PQ radially 1-2 mm beyond the radial margin of the muscular fibers of the PQ by including a small margin of fibrous tissue from the septum of the first dorsal compartment. The fibrous rim, distally and radially, allows a secure repair of the PQ and protects the tendons from the plate.
Reflect the PQ, and release the brachioradialis (BR). Clear the fat from the volar wrist capsule.
One of the following two approaches is then taken:
Reduce the fracture, and place the plate
Alternatively, partially reduce the fracture, place the distal row(s) of screws, and use the plate to obtain the final few degrees of volar tilt
If unreduced intra-articular comminution is noted, a different approach is required. Release the BR, if it was not released previously. Release the first dorsal compartment from the radius, and pronate the radius shaft away from the articular fragments. Using the carpus as a template, reduce the intra-articular fragments, perform pinning or bone grafting (or both) as necessary, and then supinate the radial shaft and continue as above.
Document the reduction using the facet lateral view and the facet posteroanterior (PA) view with the mini C-arm and with fluoroscopic views in the facet manner, aligning the view with the joint surface, not the clinical position of the forearm.
Be careful to assess the position of the tip of each distal screw. The radial styloid screw may be either in the joint or outside the radial cortex radially, and facet or oblique views must be obtained to evaluate this possibility (standard PA and lateral views will not suffice for this purpose). The distal screws should not extend beyond the dorsal cortex; indeed, they probably should be 2 mm short of the dorsal cortex. The dorsal cortex is very thin and usually comminuted; therefore, it provides no increase in fixation security. Carefully check for past-pointing; as little as 1 mm of past-pointing can shred a dorsal tendon if it is precisely in the wrong place.
Close the PQ securely with interrupted sutures, being sure to close soft tissue over the distal edge of the plate. The shaft need not be covered, because the tendons are not in contact with the shaft. No intermediate closure is needed. Close the skin.
The key to external fixation is placing the pins through small open incisions. Blind percutaneous placement or placement through small stab incisions increases the rate of nerve and tendon injury and makes it easier to create open section defects and off-center placements into the bones.
Proximally, the plane of dissection should be dorsolateral, not directly lateral, through the extensor carpi radialis longus and brevis or through the extensor carpi radialis brevis and the extensor digitorum communis. This approach avoids placing the pins near the radial sensory nerve and minimizes the risk of injuring it upon pin insertion or removal or subjecting it to the minor cellulitis of the pin tract.
Postoperative management varies. Most casts are kept on for 6 weeks, but some compressed fractures require only a splint. Most external fixators are kept in place for 6 weeks, but 8 weeks is also common; and some fractures that are not bone-grafted still collapse at 3 months. Volar fixed-angle plates require no splinting, and ROM can start at 3 days. Spanning internal fixation plates are usually removed at 3 months, and therapy is initiated at that time. It is difficult to make useful generalizations.
It is important that volar plates be evaluated via facet views, not standard PA and lateral views. For both the PA facet view and the lateral facet view, the right amount of tilt can be achieved by placing a roll of cast padding under the wrist.
It is advantageous to discuss postoperative hand therapy with the patient and arrange the appropriate appointments before surgical treatment; this includes obtaining the required authorization. Otherwise, the full benefits of the procedure may be lost because of paperwork issues.
As a rule, DRFs heal quickly. Nonunion is usually not an issue; the most common problem is malunion before or after treatment is initiated. Careful attention to follow-up radiographs helps avoid this problem. Each type of operative treatment has its own complications.[28, 29, 30]
Percutaneous pinning has two principal areas of complications: insertion problems (injury to the radial sensory nerve) and late problems (infected pin sites). The former can be mitigated by limiting the number of times a pin is placed, the latter by appropriate pin care. Although there is no consensus on appropriate pin care, most agree that the pin site should be kept clean and that showering is helpful. Early oral antibiotic therapy is usually successful in controlling pin site problems; if not, prompt pin removal usually cures the problem. Osteomyelitis is rare (<1% of cases).
External fixation also has two areas of complications: insertion problems (injury to the radial sensory nerve, tendon injuries, and open section defects in the bone) and late problems (infected pin sites). Insertion problems were addressed in 1990 by Seitz, who advocated open pin placement. Insertion problems with this technique should be rare. As with percutaneous pinning, early oral antibiotic therapy is usually successful for controlling pin-site problems; if not, prompt pin removal usually cures the problem.
Dorsal plate complications are primarily related to the close apposition of the extensor tendons to the bone. Whereas many plates claim to be low-profile to avoid this problem, 2-mm plates in a 1-mm space are still too large and may cause tendon irritation. Tendon rupture is also a potential problem, likely related to specific plate design or application and perhaps influenced by the composition of the fixation device. Many authors routinely remove their plates. The dorsal approach has largely been relegated to fractures that can only be addressed via this approach.
Volar-plate complications are only now becoming identified, and they can be classified as either dorsal or volar problems.
Dorsal problems are related to past-pointing of the distal screws (ie, screw tips extending beyond the bone). Most orthopedic screws are designed with cutting flutes at the tip, and optimum bicortical purchase requires an amount of past-pointing approximately equal to one screw diameter. However, because of the design of most volar fixation systems in which the screws lock to the plate, the dorsal cortex does not offer additional fixation. Additionally, the dorsal cortex is thin and often comminuted.
Thus, secure fixation comes from the plate and the subchondral bone. Any past-pointing of the distal screws endangers the extensor tendons, which are in close apposition to the bone. For a case example, see David Nelson, Case 2.
Volar problems with volar plates come from contact of the tendons with the plates, particularly with titanium plates. This can be due to poor plate design (eg, extension distal to the PQ, out over the volar capsule, or excessive thickness at the distal margin of the plate so that it extends volar to the PQ) or to loss of reduction, so that the flexor tendons are forced to use the plate as a fulcrum.
Spanning plates require a second surgical procedure for plate removal. Although removal is not a complication per se, in that it is planned, it is a drawback to the procedure that is not shared by the other techniques used to treat DRFs.
Fractures treated with a cast require close follow-up to observe for subsidence. Although fractures that have been reduced are most at risk, even fractures that were accepted and not reduced can still subside further and necessitate reassessment. The general rule for fractures that were reduced is to obtain a radiograph at weekly intervals for the first 3 weeks, being careful to compare the current film with the original reduction film; minor degrees of subsidence may not be evident if the current film is compared only with the most recent film.
Instability and the likelihood of further subsidence are demonstrated by any loss of the original reduction. A common error is to accept the minor increase in loss of reduction at each week, expecting that the subsidence will cease, and then to discover at 3 weeks or later that the current alignment is unacceptable after the fracture has healed and is not reducible by closed means.
Fractures stabilized operatively should be followed at 7-10 days, as the surgeon prefers. Subsidence is rarely an issue, but the possibility should be evaluated by means of radiography.
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