Practice Essentials
Distal radius fractures (DRF) are common injuries; about 643,000 were found to occur each year in the United States 1998 National Hospital Ambulatory Care Survey, [1] with about 372,000 occuring in the population aged 65 years or older. [2] The number of fractures will increase over time as the population ages. Much has been written about DRFs: as of July 2022, there were more than 1800 papers in the literature, 628 of which were published in the preceding 12 months.
DRFs, in the times of Hippocrates and Galen, were thought to be wrist dislocations. Pouteau first varied from this tradition when he described a variety of forearm fractures in the French literature in 1783, including a DRF. As a result, DRFs are termed Pouteau fractures in the French-speaking world. However, politics and communications being what they were in 18th-century Europe, the English-speaking world did not recognize the Pouteau description.
The Irish surgeon Abraham Colles described DRFs in the 1814 volume of the Edinburgh Medical Surgical Journal. Although his description was based on clinical examination alone (radiography was not invented until 1895, 81 years later), it is quite accurate, and it is Colles' name that is most often associated with this fracture in the English-speaking world. Colles stated, "One consolation only remains, that the limb will at some remote period again enjoy perfect freedom in all of its motions and be completely exempt from pain...." This claim—that all DRFs, despite displacement, will fare well—has been a source of widespread criticism.
Over time, other eponyms have been added to the various subclassifications of DRFs (eg, Smith fracture, Barton fracture, and volar Barton fracture). The fractures are also referred to as various stages of classification systems, such as a Melone IV or an AO (ie, Arbeitsgemeinschaft für Osteosynthesefragen [Association for the Study of Osteosynthesis]) C3 fracture, or are referred to the region of the fracture (eg, radial styloid or lunate facet fracture), or have a historical explanation (chauffeur's fracture, so called because a chauffeur sustained this injury when he tried to crank-start a car and it backfired).
In current practice, as a result of greater knowledge of the varieties of fracture configurations, eponyms tend to be avoided, and a direct description of the fracture is preferred. The term DRF properly covers all fractures of the distal articular and metaphyseal areas. Although all classification systems have serious problems, there is general agreement on the meaning of at least some of the classification terms (eg, Melone IV or AO C3 fracture), and these terms do add some degree of specificity and understanding to the generic designation DRF. (See Classification.)
The ultimate aim of treatment is to restore each patient to his or her prior level of functioning. The specific goals, therefore, will not be the same in all patients. For example, a 21-year-old athlete wants to resume competition, but an 82-year-old person usually only wants to return to activities of daily living (ADLs). [3, 4]
Because goals differ, treatment options differ as well. In addition, because people now remain active until an older age, the definition of "prior level of functioning" is changing. For example, a 92-year-old patient who was being treated in the emergency department (ED) had only one concern when conversing with his physician: how soon he could return to playing golf (he had a tournament the next week). Treatment goals, therefore, must be tailored to each patient. Specifically, treatment should be determined not by age but by activity level.
Anatomy
Treatment of a DRF depends on a solid understanding of the anatomy of the radius.
On the volar surface of the radius (see the image below), the lunate facet is to the left and the scaphoid facet to the right. The projection of bone just proximal and volar to the lunate facet is the lunate facet buttress. This is relevant because it is what supports the lunate facet, and it must be stabilized in volarly unstable fractures. The volar radial tuberosity is at the right margin of the bone, at the radial margin of the watershed line (see below). The surface is covered with the pronator quadratus (PQ). The cortical bone is quite thick and is strong, even in osteoporotic patients.
On the dorsal surface of the radius (see the image below), the Lister tubercle is seen in the center. This bone is a thin cortical shell, with little structural strength.
The radial surface of the radius is shown in the image below.
The ulnar surface of the radius, with the sigmoid notch for articulating with the ulna, is shown in the image below.
On the distal articular surface of the radius (see the image below), the scaphoid facet is to the right and the lunate facet to the left. This bone is the strongest of all the surfaces, and even if it is osteoporotic, it is quite strong.
A normal posteroanterior (PA) radiograph of the radius is shown in the image below. The ulna is generally within (plus or minus) 2 mm of the radius.
A normal lateral radiograph is shown in the image below. Note that the center of the lunate facet overlies the volar surface of the bone.
Several anatomic landmarks are important for the volar approach to the radius (see the image below).
Volar anatomic landmarks important for volar approach. Region marked "pronator fossa" is covered by pronator quadratus (PQ) . It extends distally to PQ line, marked in blue. Watershed line (WS) marks highest crest (most volarly projecting surface) of radius. Red X marks volar radial tuberosity, which lies just off PQ. It is usually not dissected and therefore usually not seen, but it is easily palpable clinically. VR = volar radial ridge.
Pathophysiology
The pathophysiology of a fracture is rather obvious: more load is imparted to the bone than the bone can sustain. Osteoporotic bone can break with very low impact. However, the patient should always be questioned regarding the circumstances of the injury, especially if he or she is older. Heart attacks or transient ischemic attacks (TIAs) can cause a DRF and should not be overlooked.
In addition, more problems may be involved with the injury besides the fracture itself. Although it is typical to think of the injury as involving only a broken bone, it is also worthwhile to consider that a DRF is a soft-tissue injury surrounding the broken bone; the immediacy of the radiographic diagnosis should not distract the surgeon from carefully assessing systemic issues or forearm soft-tissue issues. [5]
Etiology
The standard DRF occurs in older patients, who have much weaker bones and can sustain a DRF from simply falling on an outstretched hand in a ground-level fall. An increasing awareness of osteoporosis has led to these injuries being termed fragility fractures, the implication being that a workup for osteoporosis should be a standard part of treatment. As the population lives longer, the frequency of this type of fracture will increase.
Younger patients have stronger bone, and thus, more energy is required to create a fracture in these individuals. Motorcycle accidents, falls from a height, and similar situations are causes of high-energy DRFs, and such fractures must considered to be a separate entity from the fractures in the older population. The injury to bone and soft tissue in high-energy DRFs is greater than that in typical DRFs. Trauma is the leading cause of death in the 15- to 24-year-old age group, and this is also reflected in the incidence of lesser traumas such as DRFs.
Epidemiology
DRFs are among the most common types of fracture, and many authors state that they are the single most common type of fracture. DRFs have a bimodal distribution, with a peak in younger persons (18-25 years) and a second peak in older persons (>65 years). The mechanism of injury is unique to each group, with high-energy injuries being more common in the younger group and low-energy injuries being more common in the older group. This difference has implications for treatment.
Prognosis
Unresolved treatment controversies notwithstanding, most patients can resume their previous level of activity, including competitive sports. Most patients will likely lose a few degrees of final flexion and extension, and possibly supination as well; however, these limitations generally do not prevent full function.
Although many cases have been reported in which 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, and this places demands on the distal radius that were not seen previously. Consequently, even with apparently good care, some patients are unable to resume their prior level of functioning.
Nevertheless, 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. These are the cases that prompt researchers to continue to refine the techniques and devices. [6]
Patients, however, want more concrete prognostic statements. To this end, the following may be stated:
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Most patients treated with a volar fixed-angle plate can resume nonforceful ADLs within 3 days to 2 weeks
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Patients treated with a cast have the cast removed at 6 weeks and can then start ADLs
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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
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Contact sports or activities in which the likelihood of falling on an outstretched hand is high should be delayed for approximately 4 months
It should be kept in mind that these are just general guidelines and that great variation exists among specific cases and specific physicians.
The long-term prognosis for a properly treated DRF is good, even with an intra-articular fracture. If the articular surface is not comminuted and can be reconstructed, osteoarthritis is rare. Wrist range of motion (ROM) will continue to increase, and wrist tenderness with forceful use will continue to decrease even beyond 2 years.
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Posteroanterior radiograph demonstrating typical features of common distal radius fracture: loss of radial length, loss of radial tilt, and comminution at fracture line.
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Lateral radiograph demonstrating other common features (also see preceding image) of distal radial fracture: loss of normal volar tilt and documentation that comminution is primarily in dorsal metaphysis.
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Volar surface of radius.
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Dorsal surface of radius.
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Radial surface of radius.
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Ulnar surface of radius.
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Distal surface of radius.
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Posteroanterior radiograph of normal wrist.
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Lateral radiograph of normal wrist.
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Volar anatomic landmarks important for volar approach. Region marked "pronator fossa" is covered by pronator quadratus (PQ) . It extends distally to PQ line, marked in blue. Watershed line (WS) marks highest crest (most volarly projecting surface) of radius. Red X marks volar radial tuberosity, which lies just off PQ. It is usually not dissected and therefore usually not seen, but it is easily palpable clinically. VR = volar radial ridge.
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Percutaneous pinning with Clancey technique, posteroanterior view.
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Percutaneous pinning with Clancey technique, lateral view.
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Dorsal plate fixation using Synthes Pi plate, posteroanterior view.
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Dorsal plate fixation using Synthes Pi plate, lateral view.
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Three-column concept of wrist anatomy.
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Standard (bridging) external fixation using Orthofix RadioLucent external fixator.
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Nonbridging external fixation using Howmedica Mini-Hoffman external fixator.
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Volar fixed-angle plate using Orthofix Contours VPS plate, posteroanterior view. This is facet posteroanterior view, which is tilted at same angle as tilt of distal articular surface, thus allowing assessment of intra-articular vs extra-articular placement of screws. Note that distal screws engage both radial styloid fragment and dorsal ulnar fragment.
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Volar fixed-angle plate using Orthofix Contours VPS, lateral view. This is not facet lateral view, and distal articular surface is not seen tangentially. Consequently, some screws appear to be intra-articular; however, posteroanterior view demonstrates that they are not. Note also that distal screws do not past-point dorsal cortex but instead stop few millimeters short of dorsal cortex. Because of difficulty of evaluating screw length, even with fluoroscopy, screws should stop 2-4 mm short of dorsal cortex.
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Posteroanterior view of fragment-specific fixation. Hardware to radial side is radial pin plate. Pins hold fragment in place, and pin plate gives greater stabilization to pins. Hardware to ulnar side is dorsal pin plate (also see image below), which holds dorsal ulnar corner in place. Image courtesy of Rob Medoff, MD.
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Lateral view of fragment-specific fixation. Hardware on volar side (known as wireform) is supporting subchondral bone. Hardware in center of image is pin plate along radial border of radial styloid and serves to hold large radial styloid fragment in place. Small pin plate is situated along dorsal surface. Image courtesy of Rob Medoff, MD.
