Distal Radius Fractures Clinical Presentation

Updated: Aug 06, 2018
  • Author: David L Nelson, MD; Chief Editor: Harris Gellman, MD  more...
  • Print
Presentation

History and Physical Examination

In a patient with a distal radius fracture (DRF), the history should be directed toward ascertaining the probable amount of energy involved. A fall from 20 ft (~6 m) can be associated with a larger and more complex constellation of injuries (ie, beyond the distal fracture seen on the radiograph) than would be seen with a fall from a standing position. A history of prior fractures should be sought. A history of fragility fractures helps predict the stability of any reduction. A history of multiple high-energy fractures in a younger patient helps predict the patient's ability to comply with directions.

The median nerve is always compressed by a fall on the palmar aspect of the hand that results in a DRF, and the chart note should specifically document the quality (not just the presence or absence) of median nerve function. This should be documented at each visit for the first several weeks or months,

Most therapies for DRF have implications for the median nerve. A cast or splint without a reduction may result in median nerve compromise due to pressure. A reduction, whether closed or open, involves some level of anesthesia, temporarily compromising the ability to assess the median nerve. Careful documentation of median nerve function at the first assessment is critical to planning and assessing treatment, not to mention protecting the surgeon from subsequent claims. DRFs are overrepresented in orthopedic malpractice suits.

Next:

Classification

The goals of any classification system are as follows:

  • To stratify the injuries
  • To guide treatment
  • To facilitate discussion
  • To predict outcome

Each classification system has its merits and weaknesses with respect to each goal, and often, more than one classification system is needed. (See the report How to Classify Distal Radial Fractures.)

The classification systems used most frequently for DRFs are the Frykman, Melone, AO (Arbeitsgemeinschaft für Osteosynthesefragen [Association for the Study of Osteosynthesis]), and Fernandez systems. Their key characteristics are as follows:

  • The Frykman classification highlights the injury to the distal radioulnar joint (DRUJ)
  • The Melone classification, based on the paper by Scheck, highlights the fragmentation of the articular surface, especially the dorsoulnar corner of the distal radius
  • The AO classification emphasizes the location as extra-articular, partial articular, or completely articular
  • The Fernandez classification is based on the mechanism of injury, deduced from the displacement of the bone and the location of the fracture lines

A classification system that approaches the topic from another angle categorizes fracture patterns according to the three-column concept of the wrist and proposes treatment accordingly. This approach was independently developed by Medoff in 1994 (personal communication) and by Rikli and Rigazzoni. [5] The three columns are as follows:

  • Lateral column (the radial half of the radius, including the radial styloid and the scaphoid facet, though Medoff differentiates these two)
  • Central column (the ulnar half of the radius, including the lunate facet)
  • Medial column (the ulna, the triangular fibrocartilage [TFC], and the DRUJ)

Each column is considered separately as to its need for reduction and stabilization. It should be noted that this conceptual approach does not exclude any other approaches but, rather, is complementary to them.

Three-column concept of wrist anatomy. Three-column concept of wrist anatomy.
Previous