Distal Radius Fractures Workup

Updated: Jul 11, 2022
  • Author: David L Nelson, MD; Chief Editor: Harris Gellman, MD  more...
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Plain Radiography

Plain radiographs (see the image below) are the foundation of treatment and are all that is needed for most distal radius fractures (DRFs). If the DRF 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 must be evaluated for adequacy of reduction and for an assessment of stability, even though this is an area with no clear guidelines.

Posteroanterior radiograph demonstrating typical f Posteroanterior radiograph demonstrating typical features of common distal radius fracture: loss of radial length, loss of radial tilt, and comminution at fracture line.

Computed Tomography

Computed tomography (CT) is considered by many to be useful for evaluating the articular fracture lines in an intra-articular fracture, particularly one that is comminuted, and it is sometimes helpful for planning the approach. A CT scan may be very helpful for determing optimal treatment in cases where the subchondral bone is comminuted. If the subchondral bone, particularly in the weightbearing areas of the scaphoid facet or the lunate facet, is highly comminuted, an approach that unloads the subchondral bone is warranted (eg, external fixation and bridge plating; see Treatment).

In the view of others, however, CT adds expense and delay but rarely changes the intraoperative game plan. Highly comminuted fractures that are only comminuted in the metaphysis or the distal shaft do not need a CT scan. Experience here is necessary, in that there are no clear guidelines or criteria for when to obtain a CT scan.

It should be kept in mind that whereas plain films underestimate the number of fracture lines, CT overestimates the number.

CT is necessary in planning intra-articular osteotomies for nascent malunions and mature malunions. Three-dimensional (3D) reconstructions may look impressive in presentations, but to date, they have not been very helpful in preoperative planning or postoperative assessment.

One study examined whether the locations of DRFs correlate with the areas of attachment of the wrist ligaments. [9]  Using data from CT scans of acute intra-articular DRFs, the study noted that articular DRFs were statistically more likely to occur at the intervals between the ligament attachments than at the ligament attachments. The most common fracture sites were the center of the sigmoid notch, the area between the short and long radiolunate ligaments, and the central and ulnar aspects of the scaphoid fossa dorsally.

These results suggest that CT 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. [9]  This is a very interesting approach that will likely become a standard part of understanding DRFs in the future, especially if the method can be refined.

The threshold for treatment, though not clearly defined, often involves assessing the degree of displacement (measured in 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 this level, which adds to the challenge of treating DRFs.


Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is not indicated for evaluation of bony anatomy. Physical examination, the foundation of any  workup, is limited by pain and swelling in the acute phase, and the examination of wrist ligaments by physical examination is limited. An MRI can be considered in the setting of a high-energy injury (eg, a fall from a height or a motor vehicle accident) for the assessment of ligamentous injuries.