History

On presentation, the history should include the patient's pertinent past medical history, occupation, hand dominance, mechanism of injury, and treatment history. The patient's dependence on the extremity for occupational needs and activities of daily living (ADLs) greatly affects later decision-making.

Physical Examination

Start the physical examination proximally at the shoulder, and continue distally to include the elbow, wrist, and hand. Visually inspect the wrist, and note the presence or absence of open wounds, swelling, and deformity. Pain may limit manual examination and range of motion (ROM) of the injured wrist, but investigate other proximal injuries because they may alter the treatment plan. An adequate neurologic and vascular examination with particular attention to the median nerve is essential. Tests for compartment syndrome also must be performed carefully.

Workup

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Media Gallery

The medial complex, as described by Melone, consists of the lunate facet and its ligamentous attachments, especially the strong volar ligaments. Displacement of the medial complex has important functional implications.
The basic fragments of the Melone 4-part pattern consist of the radial styloid, dorsal lunate facet die-punch fragment, volar lunate facet die-punch fragment, and radial shaft. Note that displacement of the dorsal and/or volar lunate facet die-punch fragments also alters the anatomy of the sigmoid notch articular surface; thus, it has important consequences for forearm pronation and supination.
Postsurgical lateral radiograph shows a good reduction of the fracture with a volar buttress plate.
The normal radial inclination is 22°.
The normal radial length (RL) is 12 mm, and the ulnar variance (UV) is usually neutral or negative (normal, 0-1 mm).
Lateral radiographic view demonstrates the volar tilt (normal, 11°).
Closed reduction, fracture manipulation, and motion arthroplasty of the sigmoid notch were performed under a local hematoma block. Note the flat surface of the splint along the volar distal forearm to achieve 3-point molding of the sugar-tong plaster splint.
Postreduction posteroanterior (PA) view demonstrates an adequate stable reduction of fracture fragments; thus, surgical intervention was not required.
"Six-pack" exercises as Palmer describes, are performed during the period of immobilization to encourage and maintain finger motion.
Safe pin placement is possible on the dorsal distal radius between the first and second, third and fourth, and/or fourth and fifth extensor compartments.

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Table 1. Classification and Treatment Guidelines for Distal Radius Fractures

Table 1. Classification and Treatment Guidelines for Distal Radius Fractures

Fracture	Treatment^*
A: Extra-articular
Stable (nondisplaced or reduced)	CR, splinting
Unstable (displaced)^† Dorsal displacement Large dorsal metaphyseal fragments Small dorsal metaphyseal fragments (comminuted) Volar displacement 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
B: Intra-articular
Stable (nondisplaced or reduced)	CR, splinting
Unstable (displaced)^† Dorsal fragments 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.^[26] ^* 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.

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Author

Arvind D Nana, MD Clinical Staff, Department of Orthopedic Surgery, University of North Texas Health Science Center; Consulting Staff, Department of Orthopedic Surgery, John Peter Smith Hospital

Arvind D Nana, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, Orthopaedic Trauma Association, Texas Medical Association, Texas Orthopaedic Association

Disclosure: Nothing to disclose.

Coauthor(s)

David M Lichtman, MD Adjunct Professor, Uniformed Services University of the Health Sciences School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Thomas R Hunt III, MD Professor and Chairman, Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine

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

Disclosure: Received royalty from Tornier for independent contractor; Received ownership interest from Tornier for none; Received royalty from Lippincott for independent contractor.

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; Clinical Professor of Surgery, Nova Southeastern 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, Arkansas Medical Society, Florida Medical Association, Florida Orthopaedic Society

Disclosure: Nothing to disclose.

Additional Contributors

Peter M Murray, MD Professor and Chair, Department of Orthopedic Surgery, Mayo Clinic College of Medicine; Director of Education, Mayo Foundation for Medical Education and Research, Jacksonville; Consultant, Department of Orthopedic Surgery, Mayo Clinic, Jacksonville; Consulting Staff, Nemours Children's Clinic and Wolfson's Children's Hospital

Peter M Murray, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Reconstructive Microsurgery, Orthopaedic Research Society, Society of Military Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand, Florida Medical Association

Disclosure: Nothing to disclose.

Distal-Third Forearm Fractures Clinical Presentation

History

Physical Examination

References

Tables

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