Distal Fractures of the Radius Treatment & Management

Nonsurgical treatment

The goal is to return the patient to 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 is highlighted by a recently developed approach to surgically treat stable fractures that are in acceptable alignment. For a case discussion of this approach, see Radius Fracture with Immediate Return to Work.

Many distal radius fractures (DRFs) can be treated nonoperatively.^[7] Fractures that are undisplaced or minimally displaced (the definition of minimally displaced is controversial and varies with age and activity level [see Indications] ) 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 not usually unstable), 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.^[8]

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 drives and is active out of the home but does no sports. They have an unsightly wrist clinically (with a prominent ulnar head) that has limited supination and flexion, but they do not have symptoms with ADLs. Success in these cases strongly depends on the patient, not the surgeon, making the treatment choice.

A systematic review concluded that, in patients 60 years and older with distal radius fractures, cast immobilization provided functional outcomes similar to surgical treatments (volar locking plate system, nonbridging external fixation, bridging external fixation, percutaneous Kirschner wire fixation). Cast immobilization had the worst radiographic outcome yet lowest complication rate. Additional studies are needed to evaluate the recovery rate, cost and outcomes of these treatment methods.^[9]

[#radiusdistalfractures]Surgical treatment has been traditionally reserved for displaced, irreducible fractures or reducible but unstable fractures.^[10] One approach that is becoming more popular is to surgically treat 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-inch wires into the radial styloid and the dorsal ulnar corner of the radius, crossing the fracture site) 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).^[11]

External fixation

External fixation 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 technique of application of external fixators, however, was not defined until 1990 by Seitz. More than 25 brands of external fixators are now on the market, which is a testimony to the popularity of the technique. 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 techniques internationally.^{[12, 11]}

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. Theoretical criticisms are related to the location of the rotation—that is, whether it is an instant center or a constant center and whether or not 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. Some researchers are still investigating this technique, and it is still used clinically in some regions of the world.

One study compared the complication rates in patients treated with external fixation versus volar plating of distal radius fractures. The volar plate group experienced more tendon and median nerve complications; however, the external fixation group had a significantly higher overall complication rate. While 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.^[13] This author is a proponent of external fixators; however, note that at this time, most surgeons would place a volar plate rather than an external fixator when feasible. The rate of complications of volar plating (tendon irritation, tendon rupture, loss of fixation, inadequate fixation, plate removal) has dramatically decreased.

Some studies have shown that open reduction and internal fixation resulted in better grip strength and range of motion than closed reduction and bridging external fixation in the treatment of nonreducible distal radial fractures. The results from one study noted that these benefits diminished with time; after a mean of 5 years, both groups had approached normal values.^[14]

Dorsal plating

Dorsal plating had its greatest popularity in the 1990s, with the development of plates specifically for the distal radius. The technique has lost most of its appeal for most fractures because of tendon irritation problems.

Fragment-specific fixation

Fragment-specific fixation was originated by Fernandez, which he called 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. They lend themselves to many types of fractures, but the technique is difficult to learn and, many times, the plates must be removed.

Nonspanning external fixation

Nonspanning external fixation was popularized by McQueen and capitalized on the strength of the subchondral bone and the volar cortex. While the proponents touted the possibility of early motion, others found that the range of motion was poor.

Volar plating

Volar plating, especially for dorsally unstable fractures, was independently developed by Orbay, Jennings, and Drobetz, but Orbay successfully developed a practical device, promoted it internationally, and was the first to publish information on it.^{[15, 16]} Orbay is properly considered the grandfather of the technique. It is gaining in popularity, but its complications, particularly the incidence of tendon rupture, are now becoming recognized.^{[17, 11, 18, 19, 20, 21]}

One study compared the complication rates in patients treated with external fixation versus volar plating of distal radius fractures. The volar plate group experienced more tendon and median nerve complications; however, the external fixation group had a significantly higher overall complication rate. While 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.^[13] This author is a proponent of external fixators; however, note that at this time, most surgeons would place a volar plate rather than an external fixator when feasible. The rate of complications of volar plating (tendon irritation, tendon rupture, loss of fixation, inadequate fixation, plate removal) has dramatically decreased.

The results from another study noted that extra-articular and simple intra-articular distal radial fractures realized similar outcomes in motion, grip strength, Gartland and Werley scores, and DASH scores at 2 years when treated with open reduction and internal fixation with a volar locking plate.^[22]

Spanning internal fixation plates

Spanning internal fixation plates were originated by Becton and popularized by Ruch,^[23] 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 very new and only a few series have been published.

Surgical techniques internationally

Despite the many techniques and the large number of studies on distal radius fractures (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.

Percutaneous pinning (Clancey technique)

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-inch Kirschner wire into the radial styloid. Using image intensification, drive the Kirschner 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. The second pin is placed 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.

Percutaneous pinning (Kapandji technique)

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 called arum pins for this purpose.

Volar plating

The skin incision is made directly over the flexor carpi radialis (FCR) tendon. The incision should be approximately 10 cm long and does not need to 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 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 flexor pollicis longus, originating from the shaft of the ulna or the septum between the radius and the first dorsal compartment. The pronator quadratus (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 just 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. This line is called the 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.

There are 2 different approaches: (1) reduce the fracture and place the plate or (2) partially reduce the fracture, place the distal row(s) of screws, and then 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 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, pin and/or bone graft as necessary, and then supinate the radial shaft and continue as above.

Document the reduction using the facet lateral view and the facet 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. 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. Past-pointing of even 1 mm can shred a dorsal tendon if it is precisely in the wrong place. Carefully check for past-pointing.

Close the PQ securely with interrupted sutures. No intermediate closure is needed. Close the skin.

External fixation

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 straight lateral, through the extensor carpi radialis longus and brevis or through the extensor carpi radialis brevis and the extensor digitorum communis. This avoids placing the pins near the radial sensory nerve and 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 are moved anywhere from 3 days to 3 weeks. 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 advantageous to discuss postoperative hand therapy with the patient and arrange the appropriate appointments prior to surgery, including obtaining required authorization. Otherwise, the full benefits of the procedure may be lost because of paperwork issues.

Fractures treated with a cast require close follow-up to observe for subsidence. Although fractures that have been reduced are the most at risk, even fractures that were accepted and not reduced can still subside further and require 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 compared 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 discovering at 3 or more weeks 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 should not be an issue.

Distal radius fractures (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 operative treatment has its own complications.^{[24, 25, 26]}

Percutaneous pinning

Percutaneous pinning has 2 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. While no consensus has been reached on appropriate pin care, most agree that the pin site should be kept clean and that showering helps in this endeavor. Early oral antibiotic therapy is usually successful for controlling pin site problems; if not, prompt pin removal usually cures the problem. Osteomyelitis is rare (< 1%).

External fixation

External fixation also has 2 areas of complications: insertion problems (injury to the radial sensory nerve, tendon injuries, open section defects in the bone) and late problems (infected pin sites). Insertion problems were addressed in a landmark paper by Seitz in 1990, in which he 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 plates

Dorsal plate complications are primarily related to the close apposition of the extensor tendons to the bone. While 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 by a dorsal approach.

Volar plates

Volar plate complications are only now becoming identified, and they can be classified as dorsal or volar problems. Dorsal problems are related to past-pointing (screw tips extending beyond the bone) of the distal screws. Most orthopedic screws are designed with cutting flutes at the tip, and optimum bicortical purchase requires approximately a screw diameter of past-pointing. However, due to 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. 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.^[27] 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 (extension distal to the PQ, out over the volar capsule; or excessive thickness at the distal margin of the plate such that it extends volar to the PQ) or loss of reduction, such that the flexor tendons are forced to use the plate as a fulcrum.

Spanning plates

Spanning plates require a second surgical procedure for plate removal. While not a complication per se, because it is planned, it is a downside to the procedure that is not common to the other techniques.

In spite of the number of unresolved controversies, most patients are able to resume their previous level of activity, including competitive sports. While many cases are described in which the return to function was not limited by malunion or complications, patients are, in general, living longer and continuing to be active longer than in previous generations. This places demands on the distal radius that have not been seen previously, and despite apparently good quality care, some patients are not able to resume their previous level of functioning.

All treatment approaches have a percentage of poor results, with decreased supination, prominent ulnar heads, ligamentous problems, distal radioulnar problems (usually instability), and degenerative joint disease being common problems. These are the cases that prompt researchers to continue to refine the techniques and devices.^[28]

Patients, however, want more concrete prognostic statements. Most patients treated with a volar fixed-angle plate can resume nonforceful activities of daily living (ADLs) within 3 days to 2 weeks. Patients treated with a cast have the cast removed at 6 weeks and can then start ADLs. Grip strengthening can often be started at 2 months after any type of treatment, but forceful use of the hand should be delayed for 3 months. Contact sports or activities in which the likelihood of falling on an outstretched hand is high should be delayed for approximately 4 months. These are just general guidelines, and great variation exists among specific cases and specific physicians.

The long-term prognosis for a properly treated distal radius fracture (DRF) is good, even with an intra-articular fracture. Osteoarthritis is rare if the articular surface is not comminuted and is able to be reconstructed. Wrist range of motion will continue to increase, and wrist tenderness with forceful use will continue to decrease even beyond 2 years.

The field of distal radius fractures (DRFs) has always been an area of intense research and innovation. It has changed more rapidly in the last 5 years than in any previous 2 decades. While percutaneous pinning and external fixation remain the mainstays of treatment throughout much of the world, with strong and somewhat idiosyncratic national trends due to the prominence of individual surgeons in those countries, volar fixed-angle plating has become popular and dramatically shifted the landscape in several ways.^{[17, 29]}

For many surgeons, the volar approach for dorsally unstable DRFs, using fixed-angle devices, is the main treatment option. Orbay has popularized this treatment and broadened its applicability to highly comminuted intra-articular fractures with the extended FCR approach, pronating the radial shaft out of the way and looking directly at the undersurface of the articular bone. The low rate of complications and postoperative pain, the quality of the results, and the rapid return to activities has, for some surgeons, shifted the balance of risks to benefits such that they are offering patients the option of surgery versus a cast for stable undisplaced or stable reducible fractures.^{[15, 16]} See Radius Fracture with Immediate Return to Work.

Volar fixed-angle plates have been used widely for approximately 6 years, and the rate of complications for this technique is not yet defined. The author has found 43 cases of tendon injury or rupture, but most cases 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, placing 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. While 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.