Distal Fractures of the Radius Workup

  • Author: David L Nelson, MD; Chief Editor: Harris Gellman, MD   more...
 
Updated: Mar 7, 2012
 

Imaging Studies

Plain radiographs are all that is needed for most fractures.

CT scans are useful for evaluating the articular fracture lines and degree of comminution, and they are sometimes useful for planning the approach. Remember that plain films underestimate the number of fracture lines and that CT scans overestimate the number of fracture lines. CT scans are necessary when planning intra-articular osteotomies for nascent malunions and mature malunions. Three-dimensional reconstructions may look impressive in presentations, but to date, the resolution has not been very helpful in preoperative planning or postoperative assessment.

One study examined whether the location of distal fractures of the radius correlate with the areas of attachment of the wrist ligaments. Using data from CT scans of acute intra-articular distal radius fractures, the study noted that articular fractures of the distal radius were statistically more likely to occur at the intervals between the ligament attachments than at the ligament attachments. The most common fracture sites were noted as the center of the sigmoid notch, between the short and long radiolunate ligaments, and the central and ulnar aspects of the scaphoid fossa dorsally.

These results suggest that CT scans may be used to identify the subsequent propagation of the fracture and the likely site of the impaction of the carpus on the distal radius articular surface.[6] This is a very interesting approach that will likely become a standard part of understanding distal radius fractures in the future, especially if the method can be refined.

MRI is not indicated for evaluation of bony anatomy.

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Diagnostic Procedures

  • Plain radiographs are the foundation of treatment. If the fracture is placed in traction as an early part of treatment, traction radiographs are very helpful. Often, the fragments cannot be adequately identified or assessed on the injury films; the traction views are often the first radiographs that define the fragments. Final reduction films need to be evaluated for adequacy of reduction and for an assessment of stability, even though this is an area with no clear guidelines.
  • CT can be useful to assess the articular comminution. Importantly, however, note that plain films underestimate the number of fragments, while the CT scan overestimates them. Three-dimensional reconstructions are usually not useful.
  • The threshold for treatment, while not clearly defined, often involves assessing the displacement in terms of millimeters. Both plain films and CT scans have been evaluated for their accuracy at the 1 mm level. Neither modality can reliably be read at the 1 mm level, adding to the challenge of treating distal radius fractures (DRFs).
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Contributor Information and Disclosures
Author

David L Nelson, MD  Consulting Surgeon, Private Practice

David L Nelson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, California Orthopedic Association, Orthopaedic Research Society, and Western Orthopaedic Association

Disclosure: Orthofix Royalty Other; Howmedica Royalty Other; Synthes Honoraria Speaking and teaching; Howmedica Grant/research funds Speaking and teaching; Approximately 25 companies Grant/research funds Speaking and teaching

Specialty Editor Board

A Lee Osterman, MD  Director of Hand Surgery Fellowship, Director, Philadelphia Hand Center; Director, Professor, Department of Orthopedic Surgery, Division of Hand Surgery, University Hospital, Thomas Jefferson University

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Thomas R Hunt III, MD  John D Sherrill Professor and Director of Orthopedic Surgery, Director of Hand and Upper Extremity Fellowship, University of Alabama at Birmingham School of Medicine; Surgeon-in-Chief, UAB Highlands Hospital

Thomas R Hunt III, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, American Society for Surgery of the Hand, AO Foundation, Mid-America Orthopaedic Association, and Southern Orthopaedic Association

Disclosure: Tornier Royalty Independent contractor; Tornier Ownership interest None; Lippincott Royalty Independent contractor

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD  Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

References

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Posteroanterior radiograph demonstrating the typical features of a common distal radius fracture: loss of radial length, loss of radial tilt, and comminution at the fracture line.
Lateral radiograph demonstrating the other common features (also see Image 1) of a distal radial fracture: loss of the normal volar tilt and documentation that the comminution is primarily in the dorsal metaphysis.
Volar surface.
Dorsal surface.
Radial surface.
Ulnar surface.
Distal surface.
Posteroanterior radiograph.
Lateral radiograph.
Volar anatomic landmarks important for the volar approach. The region marked pronator fossa is covered by the pronator quadratus (PQ) muscle. It extends distally to the PQ line, marked in blue. The watershed line marks the highest crest (most volarly projecting) surface of the radius. The red X marks the volar radial tuberosity, which lies just off the pronator quadratus. It is usually not dissected and therefore usually not seen, but it is easily palpable clinically. VR marks the volar radial ridge.
Percutaneous pinning with the Clancey technique, posteroanterior view.
Percutaneous pinning with the Clancey technique, lateral view.
Dorsal plate fixation using the Synthes Pi plate, posteroanterior view.
Dorsal plate fixation using the Synthes Pi plate, lateral view.
The 3-column concept.
Standard (bridging) external fixation using an Orthofix RadioLucent external fixator.
Nonbridging external fixation using the Howmedica Mini-Hoffman external fixator.
Volar fixed-angle plate using the Orthofix Contours VPS plate, posteroanterior view. This is a facet posteroanterior view, which is tilted at the same angle as the tilt of the distal articular surface, which allows assessment of the intra-articular versus extra-articular placement of the screws. Note that the distal screws engage both the radial styloid fragment and the dorsal ulnar fragment.
Volar fixed-angle plate using the Orthofix Contours VPS, lateral view. This is not a facet lateral view, and the distal articular surface is not seen tangentially, which makes some of the screws appear to be intra-articular. However, the posteroanterior view demonstrates that they are not. Note also that the distal screws do not past-point the dorsal cortex, but instead, they stop a few millimeters short of the dorsal cortex. Due to the difficulty of evaluating screw length, even with fluoroscopy, the screws should stop 2-4 mm short of the dorsal cortex.
PA view of fragment-specific fixation (courtesy of Rob Medoff, MD). The hardware to the radial side is a radial pin plate. The pins hold the fragment in place, and the pin plate gives greater stabilization to the pins. The hardware to the ulnar side is a dorsal pin plate (also see image below), which holds the dorsal ulnar corner in place.
Lateral view of a fragment-specific fixation (courtesy of Rob Medoff, MD). The hardware on the volar side is called a wireform and is supporting the subchondral bone. The hardware in the center of the image is a pin plate along the radial border of the radial styloid and serves to hold the large radial styloid fragment in place. There is a small pin plate along the dorsal surface.
 
 
 
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