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Introduction
  • Most common orthopaedic injury with a bimodal distribution
    • younger patients - high energy
    • older patients - low energy / falls
  • 50% intra-articular
  • Associated injuries
    • DRUJ injuries must be evaluated 
    • radial styloid fx - indication of higher energy
    • soft tissue injuries in 70%
      • TFCC injury 40%
      • scapholunate ligament injury 30%
      • lunotriquetral ligament injury 15%
  • Osteoporosis
    • high incidence of distal radius fractures in women >50
    • distal radius fractures are a predictor of subsequent fractures
      • DEXA scan is recommended in woman with a distal radius fracture
Classification
  • Fernandez: based on mechanism of injury
  • Frykman: based on joint involvement (radiocarpal and/or radioulnar) +/- ulnar styloid fx
  • Melone: divides intra-articular fxs into 4 types based on displacement
  • AO:  comprehensive but cumbersome
  • Eponyms: see table for list of commonly used eponyms
Eponyms
Die-punch fxs A depressed fracture of the lunate fossa of the articular surface of the distal radius
Barton's fx Fx dislocation of radiocarpal joint with intra-articular fx involving the volar or dorsal lip (volar Barton or dorsal Barton fx)
Chauffer's fx Radial styloid fx
x
Colles' fx Low energy, dorsally displaced, extra-articular fx
Smith's fx Low energy, volar displaced, extra-articular fx
 
Imaging
  • Radiographs
View
Measurement
Normal
Acceptable criteria 
AP Radial height 13 mm <5 mm shortening 
  Radial inclination 23 degrees change <5° 
  Articular stepoff congruous <2 mm stepoff 
LAT Volar tilt 11 degrees dorsal angulation <5° or within 20° of contralateral distal radius 
  • CT scans
    • important to evaluate intra-articular involvement and for surgical planning
  • MRI useful to evaluate for soft tissue injury
    • TFCC injuries
    • scapholunate ligament injuries (DISI)
    • lunotriquetral injuries (VISI)
Treatment
  • Successful outcomes correlate with
    • accuracy of articular reduction
    • restoration of anatomic relationships
    • early efforts to regain motion of wrist and fingers
  • Nonoperative 
    • closed reduction and cast immobilization
      • indications
        • extra-articular
        • <5mm radial shortening
        • dorsal angulation <5° or within 20° of contralateral distal radius
      • technique (see below)
  • Operative
    • surgical fixation (CRPP, External Fixation, ORIF)
      • indications: radiographic findings indicating instability (pre-reduction radiographs best predictor of stability) 
        • displaced intra-articular fx
        • volar or dorsal comminution
        • articular margins fxs
        • severe osteoporosis
        • dorsal angulation >5° or >20° of contralateral distal radius
        • >5mm radial shortening
        • comminuted and displaced extra-articular fxs (Smith's fx)
        • progressive loss of volar tilt and loss of radial length following closed reduction and casting
        • associated ulnar styloid fractures do not require fixation 
Closed reduction and cast immobilization
  • Indications
    •  most extra-articular fxs
  • Technique
    • rehabilitation
      • no significant benefit of physical therapy over home exercises for simple distal radius fractures treated with cast immobilization
  • Outcomes
    • repeat closed reductions have 50% less than satisfactory results
  • Complications
    • acute carpal tunnel syndrome
      • (see complications below)
    • EPL rupture
      • (see complications below) 
Percutaneous Pinning
  • Indications
    • can maintain sagittal length/alignment in extra-articular fxs with stable volar cortex
    • cannot maintain length/alignment when unstable or comminuted volar cortex
  • Techniques
    • Kapandji intrafocal technique
    • Rayhack technique with arthroscopically assisted reduction
  • Outcomes
    • 82-90% good results if used appropriately
External Fixation
  • Indications
    • alone cannot reliably restore 10 degree palmar tilt
      • therefore usually combined with percutaneous pinning technique or plate fixation
  • Technical considerations
    • relies on ligamentotaxis to maintain reduction 
    • place radial shaft pins under direct visualization to avoid injury to superficial radial nerve
    • nonspanning ex-fix can be useful if large articular fragment
    • avoid overdistraction (carpal distraction < 5mm in neutral position) and excessive volar flexion and ulnar deviation
    • limit duration to 8 weeks and perform aggressive OT to maintain digital ROM
  • Outcomes
    • important adjunct with 80-90% good/excellent results
  • Complications
    • malunion/nonunion
    • stiffness and decreased grip strength
    • pin complications (infections, fx through pin site, skin difficulties)
      • pin site care comprising daily showers and dry dressings recommended 
    • neurologic (iatrogenic injury to radial sensory nervemedian neuropathy, RSD)
ORIF
  • Indications
    • significant articular displacement (>2mm)
    • dorsal and volar Barton fxs
    • volar comminution
    • metaphyseal-diaphyseal extension
    • associated distal ulnar shaft fxs
    • die-punch fxs
  • Technique
    • volar plating
      • volar plating preferred over dorsal plating
      • volar plating associated with irritation of both flexor and extensor tendons
        • rupture of FPL is most common with volar plates  
        • associated with plate placement distal to watershed area, the most volar margin of the radius closest to the flexor tendons
      • new volar locking plates offer improved support to subchondral bone
    • dorsal plating
      • dorsal plating historically associated with extensor tendon irritation and rupture
      • dorsal approach indicated for displaced intra-articular distal radius fracture with dorsal comminution  
    • other technical considerations
      • can combine with external fixation and PCP
      • bone grafting if complex and comminuted
      • study showed improved results with arthroscopically assisted reduction
      • volar lunate facet fragments may require fragment specific fixation to prevent early post-operative failure 
Complications
  • Median nerve neuropathy (CTS)
    • most frequent neurologic complication
    • 1-12% in low energy fxs and 30% in high energy fxs
    • prevent by avoiding immobilization in excessive wrist flexion and ulnar deviation (Cotton-Loder Position)
    • treat with acute carpal tunnel release for:
      • progressive paresthesias, weakness in thumb opposition  
      • paresthesias do not respond to reduction and last > 24-48 hours
  • Ulnar nerve neuropathy 
    • seen with DRUJ injuries
  • EPL rupture   
    • nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the extensor pollicis longus tendon  
      • extensor mechanism is felt to impinge on the tendon following a nondisplaced fracture and causes either a mechanical attrition of the tendon or a local area of ischemia in the tendon.
    • treat with transfer of extensor indicis proprius to EPL
  • Radiocarpal arthrosis (2-30%)
    • 90% young adults will develop symptomatic arthrosis if articular stepoff > 1-2 mm
    • may be nonsymptomatic
  • Malunion and Nonunion
    • Intra-articular malunion
      • treat with revision at > 6 weeks
    • Extra-articular angulation malunion
      • treat with opening wedge osteotomy with ORIF and bone grafting
    • Radial shortening malunion
      • radial shortening associated with greatest loss of wrist function and degenerative changes in extra-articular fxs
      • treat with ulnar shortening
  • ECU or EDM entrapment
    • entrapment in DRUJ injury
  • Compartment syndrome
  • RSD/CRPS
    • AAOS 2010 clinical practice guidelines recommend vitamin C supplementation to prevent incidence of RSD postoperatively 
 

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